5:25-cv-00809•Lightenfield v. Bisignano
Testo completo
1 UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK _____________________________________________________________________ Ashley L.,1 Plaintiff, v. 5:25-CV-809 (MAD/MJK) Commissioner of Social Security Defendant. _____________________________________________________________________ Ida Comerford Esq., for Plaintiff Fergus J. Kaiser Esq., Special Asst. U.S. Attorney, for Defendant Mitchell J. Katz, U.S. Magistrate Judge To the Honorable Mae A. D’Agostino, U.S. District Judge: REPORT-RECOMMENDATION Ashley L. brought this action under the Social Security Act (42 U.S.C. § 405(g)) seeking judicial review of the Social Security Commissioner’s final decision denying her application for benefits. (Dkt. 1.). Ashley L. did not consent to the jurisdiction of a Magistrate Judge. (Dkt. 4). So, the Honorable Mae A. D’Agostino, U.S. District Judge, referred this matter to the Court for Report and Recommendation. Both 1 This Report-Recommendation will identify the plaintiff using only her first name and last initial to protect her privacy. Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 1 of 29
2 parties filed briefs (Dkts. 11, 13, 14) which the Court treats as motions under Fed. R. Civ. P. 12(c), in accordance with General Order 18. I. PROCEDURAL HISTORY On August 8, 2022, Ashley L. filed an application for Title XVI supplemental security income benefits, alleging disability beginning May 11, 2022. (T. 10).2 The Social Security Administration denied the claim initially on March 6, 2023, and again upon reconsideration on October 10, 2023. (Id.). Ashley L. requested a hearing six days later. (Id.) Administrative Law Judge (“ALJ”) Mary Jane Pelton held a hearing on June 14, 2024. (T. 36-54). At the hearing, Matthew Nutting represented Ashley L.. (T. 39). Both Ashley L. and Vocational Expert Christine Ditrinco testified. (T. 36-54). On July 11, 2024, ALJ Pelton issued an unfavorable decision. (T. 7). The appeals council denied review. (T. 1-3). II. GENERALLY APPLICABLE LAW A. Disability Standards 2 All page references are to the Administrative Transcript (“T.”) and not the page numbers assigned by the CM/ECF pagination system. Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 2 of 29
3 To be considered disabled, plaintiffs seeking disability insurance or supplemental security income benefits must establish that they are “unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death, or which has lasted or can be expected to last for a continuous period of not less than twelve months …” 42 U.S.C. § 1382c(a)(3)(A). In addition, plaintiffs’ physical or mental impairment or impairments [must be] of s uch severity that [they are] not only unable to do [their] previous work but cannot, considering [their] age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which [they] live[], or whether a specific job vacancy exists for [them], or whether [they] would be hired if [they] applied for work. 42 U.S.C. § 1382c(a)(3)(B). The Commissioner uses a five-step process, set forth in 20 C.F.R. §§ 404.1520 and 416.920, to evaluate disability insurance and supplemental security income disability claims. First, the [Commissioner] considers whether the claimant is currently engaged in substantial gainful activity. If [they are] not, the [Commissioner] next considers whether the claimant has a “severe impairment” which significantly limits [their] physical or mental ability to do basic work activities. If the claimant suffers such an impairment, the third inquiry is whether, based solely on medical evidence, the claimant has Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 3 of 29
4 an impairment which meets or equals the criteria of an impairment listed in Appendix 1 of the regulations. If the claimant has such an impairment, the [Commissioner] will consider [them] disabled without considering vocational factors such as age, education, and work experience … Assuming the claimant does not have a listed impairment, the fourth inquiry is whether, despite the claimant’s severe impairment, [they have] the residual functional capacity to perform [their] past work. Finally, if the claimant is unable to perform [their] past work, the [Commissioner] then determines whether there is other work which the claimant can perform. Berry v. Schweiker, 675 F.2d 464, 467 (2d Cir. 1982); see also 20 C.F.R. §§ 404.1520, 416.920. Plaintiffs have the burden of establishing disability at the first four steps. See Selian v. Astrue, 708 F.3d 409, 418 (2d Cir. 2013). If they establish that their impairment prevents them from performing their past work, the burden then shifts to the Commissioner to prove the final step. Id. B. Scope of Review When reviewing a final decision of the Commissioner, courts must determine whether the correct legal standards were applied and whether substantial evidence supported the decision. Id. at 417; see also Brault v. Soc. Sec. Admin., Comm’r, 683 F.3d 443, 448 (2d Cir. 2012); 42 U.S.C. § 405(g). Substantial evidence is “such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 4 of 29
5 Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012). It must be “more than a scintilla” of evidence scattered throughout the administrative record. Id. Yet this standard is a very deferential standard of review “— even more so than the ‘clearly erroneous standard.’” Brault, 683 F.3d at 448. “To determine on appeal whether an ALJ’s findings are supported by substantial evidence, reviewing courts consider the whole record, examining the evidence from both sides, because an analysis of the substantiality of the evidence must also include that which detracts from its weight.” Williams ex rel. Williams v. Bowen, 859 F.2d 255, 258 (2d Cir. 1988). But reviewing courts may not substitute their interpretation of the administrative record for that of the Commissioner if the record contains substantial support for the ALJ’s decision. Id.; see also Rutherford v. Schweiker, 685 F.2d 60, 62 (2d Cir. 1982). ALJs need not explicitly analyze every piece of conflicting evidence in the record. See Mongeur v. Heckler, 722 F.2d 1033, 1040 (2d Cir. 1983); see also Miles v. Harris, 645 F.2d 122, 124 (2d Cir. 1981) (“[W]e are unwilling to require an ALJ explicitly to reconcile every conflicting shred of medical testimony[.]”). But ALJs cannot “‘pick and choose’ evidence in the record that supports [their] conclusions.” Cruz v. Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 5 of 29
6 Barnhart, 343 F. Supp. 2d 218, 224 (S.D.N.Y. 2004); see also Fuller v. Astrue, No. 09-CV-6279, 2010 WL 5072112, at *6 (W.D.N.Y. Dec. 6, 2010). III. FACTS The record includes Ashley L.’s medical and mental health treatment records which the parties are familiar with. The Court will refer to the pertinent records and the hearing testimony in its analysis of the parties’ claims as appropriate. IV. THE ALJ’S DECISION At step one of the five-step-sequential analysis, ALJ Pelton determined that Ashley L. has “not engaged in substantial gainful activity since August 8, 2022, the application date.” (T. 12) (cleaned up). At step two, ALJ Pelton concluded that Ashley L. “has the following severe impairments: fracture with rod placement of the right leg, fractures with metal plate of the right wrist and hand, peripheral neuropathy, traumatic brain injury, migraine, post-traumatic stress disorder, depressive disorder, and anxiety disorder.” (Id.) (cleaned up). At step three, ALJ Pelton determined that Ashley L. “does not have an impairment, or combination of impairments, that medically Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 6 of 29
7 equals the severity of one of the listed impairments in 20 C.F.R Part 404, Subpart. P, Appendix. 1.” (T. 13.) (internal citations omitted). Next, ALJ Pelton discussed the “paragraph B” criteria. (T. 15-16). “To satisfy the paragraph B criteria,” mental impairments “must result in one extreme limitation or two marked limitations in a broad area of functioning.” See 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.00(A)(2)(b) (cleaned up). The four broad areas of mental functioning are: (1) understanding, remembering, or applying information; (2) interacting with others; (3) maintaining concentration, persistence, or pace; and (4) adapting and managing oneself. See 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.00(C). Here, ALJ Pelton found that Ashley L. did not meet the “paragraph B” criteria because Ashley L. had mild limitations in understanding, remembering, or applying information, no limitation in interacting with others, moderate limitations in maintaining concentration, persistence, or pace, and mild limitations in adapting and managing oneself. (T. 15-16). The ALJ also considered the “paragraph C” criteria. (T. 16). The “paragraph C” criteria require a documented medical history of the existence of the disorder over a period of at least two years, with Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 7 of 29
8 evidence of both (a) medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of the mental disorder; and (b) marginal adjustment, that is, minimal capacity to adapt to changes in environment or to demands that are not already part of daily life. See 20 C.F.R. pt. 404, subpt. P, app. 1, § 12.00(A)(2)(c). Here, ALJ Pelton noted that the “paragraph C” criteria were not met. (Id.). After this, ALJ Greisler determined that Ashley L. had the residual function capacity (“RFC”) to perform: sedentary work as defined in 20 CFR 416.967(a) except she can lift and carry 10 pounds occasionally and less than 10 pounds frequently, can sit with normal breaks for a total of 6 hours in an 8 hour workday, and stand and/or walk with normal breaks for a total of 2 hours in an 8 hour workday. She can never climb ladders, ropes, or scaffolds, occasionally climb ramps or stairs. She can occasionally balance as defined by the Selected Characteristics of Occupations, occasionally stoop, kneel, or crouch, she should never crawl. She should avoid exposure to hazards, such as unprotected heights and dangerous moving machinery. She can understand, remember, and carry out simple instructions. She can use judgment to make simple work-related decisions. She should work in a job with occasional changes in the routine work setting. She cannot perform work requiring a specific production rate or perform work which requires hourly quotas. She could have occasional interaction with coworkers, supervisors, and the public. (T. 17). Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 8 of 29
9 To make this finding, ALJ Pelton considered “the medical opinion(s) and prior administrative medical finding(s)” pursuant to 20 C.F.R. § 416.920c. (Id.). At step four, ALJ Pelton reasoned that Ashley L. “has no past relevant work”, is within the “younger individual age 18-44” category, has “limited education,” and “transferability of skills is not an issue.” (T. 24). Finally, at step five, ALJ Pelton concluded that “considering” Ashley L.’s “age, education, work experience, and residual functional capacity, there are jobs that exist in significant numbers in the national economy that” she “can perform.” (T. 25). Accordingly, ALJ Pelton determined that Ashley L. is not disabled as defined by the Social Security Act. (T. 26). V. ISSUES IN CONTENTION Ashley L.’s argument is confusing. At first, she seems to argue that substantial evidence does not support ALJ Pelton’s decision. But in the argument section of her brief, Ashley L. focuses on ALJ Pelton’s supportability and consistency analyses as to Matthew Grier, D.O. Compare (Pl. Br. at pg. 1) with (Pl. Br. at pgs. 11-18). In contrast, the Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 9 of 29
10 Commissioner argues that substantial evidence supports ALJ Pelton’s decision. (Def. Br. at pgs. 5-11). VI. DISCUSSION The Court recommends the District Court reverse and remand ALJ Pelton’s decision. Unsure whether Ashley L.’s claim is a substantial evidence or legal error claim, the Court analyzes the claim under both standards. And under either standard, the Court finds serious errors with ALJ Pelton’s decision. A. ALJ Pelton erred when performing the supportability and consistency analyses on Dr. Angelotti’s and Dr. Grier’s opinions and those errors were not harmless. The Court recommends the District Court find that ALJ Pelton committed legal error when analyzing Ashley L.’s claim. When reviewing an agency’s decision, the reviewing court must determine if the ALJ properly applied the agency’s regulations. Here, ALJ Pelton incorrectly performed the supportability and consistency analyses as to M. Vazquez Gonzalez, M.D.’s, Angelotti, M.D.’s, and Dr. Grier’s opinions. Those errors meaningfully harmed the analysis. As a result, the District Court should reverse and remand ALJ Pelton’s decision. Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 10 of 29
11 ALJs “must consider all medical opinions and evaluate their persuasiveness based on their supportability and consistency, the author’s relationship with the claimant and specialization, and other factors.” Tyler W. v. Comm’r of Soc. Sec., No. 22-CV-01345 (CFH), 2024 WL 1075209, at *7 (N.D.N.Y. Mar. 12, 2024) (cleaned up). “The two most important factors for determining the persuasiveness of medical opinions are consistency and supportability[.]”Stephanie F. v. Kijakazi, No. 20-CV-1528 (BKS), 2022 WL 3355964, at *9 (N.D.N.Y. Aug. 15, 2022). Because that’s so, ALJs must “explain how [they] considered the supportability and consistency factors” for a medical opinion. 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). “Supportability” means that “the more relevant the objective medical evidence and supporting explanations presented by a medical source are to support his or her medical opinion(s) or prior administrative medical finding(s), the more persuasive the medical opinions or prior administrative medical finding(s) will be.” Id. §§ 404.1520c(c)(1), 416.920c(c)(1) (cleaned up). “Consistency” means that “the more consistent a medical opinion(s) or prior administrative medical finding(s) is with the evidence from other medical sources and Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 11 of 29
12 nonmedical sources in the claim, the more persuasive the medical opinion(s) or prior administrative medical finding(s) will be.” Id. §§ 404.1520c(c)(2), 416.920c(c)(2). In plain English, supportability is an internal check—examining whether the medical source references medical evidence that comes from the medical source. Consistency is an external check—examining whether the medical sources’ opinion is similar, or dissimilar, to other medical and non-medical sources. ALJs’ “failure to explain the supportability and consistency of the medical opinions in the record is procedural error.” Stephanie F., 2022 WL 3355964, at *9. And procedural errors are subject to harmless error review. See id; see also Loucks v. Kijakazi, No. 21-CV-1749, 2022 WL 2189293, at *2 (2d. Cir. 2022) (summary order). Dr. Gonzalez—who reviewed an incomplete medical record— opined that Ashely can: occasionally lift 10 pounds, frequently lift less than 10 pounds, stand and/or walk with normal breaks for 2 hours, sit with normal breaks for more than 6 hours in an 8-hour-work day, never climb ladders, ropes or scaffolds, occasionally climb ramps, stairs, balance, stoop, kneel, crouch, and crawl. (T. 65-66). Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 12 of 29
13 After reviewing the entire record, Dr. Angelotti, opined that Ashely can: occasionally lift and/or carry 20 pounds, frequently lift and/or carry 10 pounds, stand and/or walk with normal breaks for 4 hours, sit with normal breaks for more 6 hours in an 8-hour-work day, frequently climb ramps, stairs, balance, and stoop, and occasionally, climb ladders, ropes, scaffolds, kneel, crouch, and crawl. (T. 81). In April 2024, Dr. Grier—who treated Ashley L. at least once— opined that Ashley L. can: rarely lift and/or carry 50 pounds, occasionally lift and/or carry 20 pounds, and frequently lift/and or carry 10 pounds, stand/walk with normal breaks for less than 2 hours, sit with normal breaks for at least 6 hours in an 8-hour-workday, frequently twist, occasionally climb ladders and stairs, rarely crouch or squat, and never climb ladders. (T. 1948-49). ALJ Pelton erred when performing the consistency analysis on Dr. Gonzalez’s opinion. ALJ Pelton found Dr. Gonzalez’s findings “are consistent with the objective record.” (T. 23). And that statement was the extent of the consistency analysis. ALJ Pelton reasoned that “Dr. Gonzalez supported [his] findings with a review of the evidence available to [him] at that time as well as a narrative explaining the Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 13 of 29
14 prior administrative medical findings and providing references to the objective medical record.” (T. 24.). But Dr. Gonzalez’s opinion is inconsistent with the record in certain respects. Both Dr. Angelotti and Dr. Grier opined that Ashley L. could occasionally lift and/or carry 20 pounds and frequently lift/and or carry 10 pounds (T. 81, 1949). Yet Dr. Gonzalez opined that Ashley L. could occasionally lift 10 pounds and frequently lift less than 10 pounds. (T. 65). This inconsistency makes sense in context. As ALJ Pelton implicitly noted, Dr. Gonzalez did not have all evidence. See. (T. 23) (“Dr. Gonzalez supported the findings with a review of the evidence available to [him at] that time”) (emphasis added). Considering that Dr. Gonzalez did not have all the information, it makes sense for ALJ Pelton to discount Dr. Gonzalez’s testimony. See, e.g., Seth M. v. Comm’r of Soc. Sec., No. 1:24-CV-00230 (AJB/ML), 2025 WL 1089515, at *8 (N.D.N.Y. Jan. 30, 2025) (cleaned up) (noting that “[t]he ALJ found these opinions partially persuasive because their ‘opinions were based on a mere review of the medical record, which was incomplete at the time.’”); see also Martha B. Z. v. Comm’r of Soc. Sec., No. 19-CV-06494, 2021 WL 11705678, at *5 (W.D.N.Y. Jan. 15, 2021) (noting “medical source opinions that are. . . based on an incomplete Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 14 of 29
15 medical record’ may not be substantial evidence to support an ALJ finding” unless those “opinions are supported by substantially similar findings in treatment notes and other opinions in the record.”). ALJ Pelton also erred when performing the supportability analysis on Dr. Gonzalez’s opinion. ALJ Pelton found Dr. Gonzalez’s supported because Ashley L. “was in a motor vehicle accident which crushed her right leg and required placement of a metal rod in an open reduction internal fixation surgery on her leg and right-hand splint and metal plate to treat them.” (T. 23). Put differently, the “objective evidence” ALJ Pelton proffers in her supportability analysis of Dr. Gonzalez’s opinion is the fact of the accident and the fact of the surgery. (T. 23). But that proffered evidence is inconsistent with ALJ Pelton’s decision. When rejecting Ashley L.’s allegations, ALJ Pelton reasoned: treatment notes indicate that the claimant was walking and did not attend the physical therapy prescribed by treating medical service providers (Ex. 2F/8, 8F/14). It is not unreasonable to expect that an individual who experienced limitations to the extent alleged by the claimant would utilize the remedies made available to them. Yet, this is consistent with recovery are notations by treating medical service providers including “looks excellent” and “made [a] very nice recovery” and has been walking on her tibia now for several months and the claimant was “doing well overall” (Ex. 2F/8, 8F/14, 17). Treatment notes indicated normal sensation, improved active range of motion and passive range of motion, Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 15 of 29
16 and treating medical service providers encouraged exercise as part of her treatment (Ex. 17F/3, 6, 7, 12, 8F/14). (T. 18). On one hand ALJ Pelton touts the accident and surgery as a basis to find that Dr. Gonzalez’s opinion is supported, even though Dr. Gonzalez did not have all the records. (T. 23). But on the other hand, ALJ Pelton marshals evidence to show that Ashley L. can do more than she says she can. (T. 18). In essence, ALJ Pelton played doctor, which she is prohibited from doing. See Javon W. v. Comm’r of Soc. Sec., 629 F. Supp. 3d 62, 67 (W.D.N.Y. 2022) (“An ALJ is prohibited from ‘playing doctor’ in the sense that an ALJ may not substitute [her] own judgment for competent medical opinion.”). At bottom, ALJ Pelton’s analysis of Dr. Gonzalez’s “opinion fails to sufficiently explain the basis for adopting the state agency consultant’s opinion, and rejecting the” two “other opinions[.]”Amber H. v. Saul, No. 3:20-CV-490 (ATB), 2021 WL 2076219, at *6 (N.D.N.Y. May 24, 2021). ALJ Pelton erred when performing the supportability analysis on Dr. Angelotti’s opinion. For exactly the same reason ALJ Pelton found Dr. Gonzalez’s opinion supported, ALJ Pelton found Dr. Angelotti’s opinion unpersuasive. (T. 23). ALJ Pelton’s explanation was only Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 16 of 29
17 “evidence suggests that greater limitations than those stated by Dr. Angelotti are warranted.” (Id.). The ALJ neither explains what evidence—other than the accident and surgery—supports greater limitations nor cites evidence in the record to support that assertion. (Id.). That is a violation of the articulation requirement. See Stephanie F., 2022 WL 3355964, at *10 (N.D.N.Y. Aug. 15, 2022) (“[T]he ALJ’s conclusory statement that [the provider's] conclusions ‘are not consistent with the overall medical evidence’ is not an adequate articulation of the consistency factor.”). Further cutting against ALJ Pelton’s supportability analysis of Dr. Angelotti’s opinion is ALJ Pelton’s discussion of Ashley L.’s hand. When analyzing the record as to Ashley L.’s hand ALJ Pelton noted that: At her consultative examination in January 2023, [Ashley L.’s] hand and finger dexterity was intact, her grip strength was rated 5 out of a possible 5, and she was able to zip and button with both her right hand and her left hand, and she was able to tie a bow [T. 1309-10]. Additionally, the claimant reported that she is able to drive a car, a task which generally requires the ability to push and pull with one’s upper extremities to open or close a car door, to reach for and grasp a steering wheel, and to operate dashboard controls, the ability to reach to use a seatbelt [T. 234, 1592]. She also reported that she is able to perform tasks that generally require the use of one’s upper extremities, including cooking, Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 17 of 29
18 cleaning, and doing laundry [T. 1308]. Overall, such evidence suggests that the claimant is not limited to the extent alleged by fractures with metal plate of the right wrist and hand. (T. 19). Like before, ALJ Pelton marshals evidence to prove that Ashley L.’s hand is working in one section of her decision. (Id.). But when analyzing Dr. Angelotti’s opinion, ALJ Pelton claims that the simple fact of the hand injury is enough to reject Dr. Angelotti’s opinion. (T. 23). That cannot be right. ALJ Pelton’s supportability and consistency analyses of Dr Grier’s opinion is confusing. ALJ Pelton claimed that Dr. Grier’s opinion “is somewhat speculative . . . because the findings of Dr. Grier are consistent with the objective record in part.” (T. 24). Frankly this sentence makes no sense, and this Court cannot glean what the ALJ meant. The Commissioner tries to wave this sentence away by arguing that ALJ Pelton “clearly intended to state that the opinion was inconsistent with the record” but that also makes no sense. (Def. Br. at pg. 9). Reading that sentence the way the Commissioner does, ALJ Pelton’s statement is: Dr. Grier’s opinion “is a somewhat speculative opinion because the findings of Dr. Grier are [in]consistent with the objective record in part.” (T. 24). But ALJ Pelton never identifies what Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 18 of 29
19 is inconsistent—as she must. Kalieka D.B. v. Comm’r of Soc. Sec., No. 24-CV-371 (DNH/PJE) 2025 WL 2933343, at 6* (N.D.N.Y. Aug. 25, 2025) (“The ALJ must expressly explain how [they] considered the supportability and consistency factors for a medical opinion.”) (cleaned up). She again trots out Ashely’s accident and surgery as evidence of greater limitations. (T. 24.). But just like the supportability analysis of Dr. Angelotti’s opinion, ALJ Pelton’s analysis never identifies objective evidence to support her assertion. (Id.); see also Tyler W., 2024 WL 1075209 at *11, (N.D.N.Y. Mar. 12, 2024) (remanding where “the ALJ summarily concluded that [the provider]’s opinion was poorly supported and speculative,” because “such conclusory statements are insufficient to meet the articulation requirements of the regulations.”) (cleaned up). * * * All in all, the Court recommends that the District Court find that ALJ Pelton improperly performed the supportability and consistency analyses as to opinions of Drs. Gonzalez, Angelotti, and Grier. To start, this Court cannot glean why the ALJ determined that Dr. Gonzalez’s opinion was the only opinion consistent with the record. Compare (T. 23) (“The undersigned finds the prior administrative medical findings of Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 19 of 29
20 Dr. Gonzalez are consistent with the objective record.”) with Ricky L. v. Comm’r of Soc. Sec., No. 20-CV-7102-FPG, 2022 WL 2306965, at *3 (W.D.N.Y. June 27, 2022) (“Where an ALJ merely states that an examining physician’s opinion is not consistent with the overall medical evidence, he has failed to adequately explain his conclusions regarding the consistency factor.” (cleaned up)). To the extent the Commissioner can argue that ALJ Pelton’s proffered example is enough, this Court urges the District Court to reject that argument. The example ALJ Pelton uses to support her supportability and consistency analyses of Dr. Gonzalez’s opinion is the fact of the accident and the injuries—not medical issues that stem from the accident. (T. 23). ALJ Pelton also uses that same reasoning to reject the findings of Drs. Angelotti and Grier. See (T. 23-24). In essence, ALJ Pelton rejected the findings of doctors who reviewed all the medical records and treated Ashley L.— and came to similar findings—only because of the accident. That reasoning cannot stand. That is by definition playing doctor, which the ALJ is also prohibited from doing. See Javon W., 629 F. Supp. 3d at 67. To be sure, if Ashley L. argued that she is disabled simply because of her accident, ALJ Pelton would have rightly rejected that argument. Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 20 of 29
21 Adding these errors together, the District Court should find that the ALJ failed to properly apply the regulations. ALJ Pelton’s legal errors were not harmless. Here, the ALJ ignored the regulations, played doctor, and crafted an RFC without support. Cf. Laura C. v. Comm’r of Soc. Sec., 529 F. Supp. 3d 64, 71 (W.D.N.Y. 2021) (finding that meaningful judicial review was precluded when the Court was “left to speculate” about the ALJ's reasoning). And for those reasons (and those explained below) the Court recommends the District Court find that the ALJ’s errors were not harmless. B. Substantial evidence does not support ALJ Pelton’s decision because the ALJ failed to include evidence that would have changed the RFC. If the District Court disagrees with the above analysis, it should view Ashley L.’s claim as a substantial evidence claim and rule against the Commissioner. When reviewing an agency’s decision, the reviewing court must determine if substantial evidence supports the ALJ’s decision. Here, ALJ Pelton did not meaningfully engage with the evidence surrounding Ashley L.’s need for a cane, did not identify how her Class III obesity interfered with her ability to walk, cherry picked evidence, and did not engage with evidence that supported Ashley L.’s Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 21 of 29
22 claim. As a result, the Court recommends the District Court find that substantial evidence does not support ALJ Pelton’s decision. Viewing Ashley L.’s claim as a substantial evidence claim, the Court comes to the same recommendation; the claim should be remanded. ALJ Pelton did not create a logical bridge when rejecting Dr. Grier’s opinion that Ashley L. needed a cane. In her decision, ALJ Pelton reasoned that Dr. Grier’s opinion that Ashely “must use a cane to ambulate but could still perform light exertional level work.” (T. 24) (cleaned up); see also (T. 1949). But the record indicates that a cane is a medical necessity. In April 2024, Dr. Grier opined that Ashley L. needed to use a cane. (T. 1949). Similarly, January 2024, medical notes identified that Ashley L. had an antalgic gait on the right “with diminished time in stance phase on right,” a “diminished step off on right foot,” and “limited dorsiflexion on right.” (T. 2521). Like Dr Grier, in January 2023, Elke Lorensen, M.D.—a consultative examiner who assessed Ashley L.—noted that Ashley L.’s “gait is abnormal, she walks with a moderate to marked limp” and “the use of the cane is medically necessary.” (T. 1308). Dr. Lorensen also opined that using a cane Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 22 of 29
23 changed Ashley L.’s moderate to marked limp into a moderate limp. (T. 1308). More to the point, medical records showed that Ashley L.’s “mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.” (T. 472). And Ashley L., in her function report, noted that when she is shopping “someone always has to come help” her and she uses “the scooters to drive around” the “store.” (T. 234). Beyond that, in 2022, Ashely needed a gait belt and platform walker to improve mobility. (T. 1355). In sum, the record provides ample support for the medical necessity of a cane. Yet all ALJ Pelton relies on when rejecting the medical necessity of a cane is Ashley L.’s ability to drive. (T. 18). But Ashley L. testified that she only drives to doctor appointments and only does so once or twice a month. (T. 42). In fact, Ashley L. uses medical cabs to transport her to and from most appointments. See (T. 48). ALJ Pelton’s reasoning is a catch-22. ALJ Pelton penalizes Ashely for the way she travels to her appointments and for the fact that she did not travel to some appointments. (T. 18, 24). Altogether, ALJ Pelton’s decision to discount Ashley L.’s cane use is error. Cf. Rowe v. Berryhill, No. 1:17-CV-00208, 2018 WL 4233702, at *4 (W.D.N.Y. Sept. 6, 2018) (finding that “the Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 23 of 29
24 ALJ's discussion of [the] [p]laintiff's use of the cane inadequate[,]” where a “discharge summary noted the cane should be used to assist with ambulation for four weeks[,]” and “the record contains several instances where Plaintiff's range of motion was limited[.]”). The Court cannot glean why ALJ Pelton rejected two cane opinions. Considering (1) Ashley L.’s Class III obesity—Ashley L. is 5’0, 247 pounds, with 43.07% of body fat—(2) Ashley L.’s abnormal gait, (3) opinions from two doctors who assessed Ashley L. and determined that she needed a cane, and (4) the surgical repairs to Ashley L.’s leg, it’s hard to understand why ALJ Pelton rejected Dr. Grier’s opinion that Ashley L. needed a cane. See Gabriel A. v. Comm’r of Soc. Sec., No. 1:24- CV-00389, 2025 WL 2653116, at *7 (W.D.N.Y. Sept. 16, 2025) (reversing and remanding the ALJ’s decision because the ALJ failed to build a logical bridge when improperly considering the plaintiff’s need for a cane).3 Worse still, when analyzing Ashley L.’s obesity ALJ Pelton only notes that “the record contains a general lack of evidence that would 3 “Class III obesity, formerly known as morbid obesity, is a complex chronic disease in which you have a body mass index (BMI) of 40 or higher.” Cleveland Clinic, Class III Obesity (Formerly Known as Morbid Obesity), https://my.clevelandclinic.org/health/diseases/21989-class-iii-obesity-formerly- known-as-morbid-obesity (last visited Mar. 11, 2026). Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 24 of 29
25 indicate that the claimant experiences exertional or non-exertional limitations specifically due to obesity.” (Id.). But it seems obvious that Class III obesity affects an individual’s ability to ambulate. Cf. Rivera v. Saul, No. 3:19-CV-00944, 2020 WL 13551953, at *13 (D. Conn. July 28, 2020) (“The ALJ concluded that Rivera’s BMI, which ranged from the high fifties up to sixty, constituted morbid obesity and restricted his ability to undergo hip surgery.”). Adding to the list of errors, ALJ Pelton cherry picked evidence. ALJ Pelton ignores Dr. Lorensen’s statement that a cane is medically necessary. (T. 23-4). ALJ Pelton references medical records, which state that Ashley L. was not attending physical therapy, yet she ignores any discussion of the medical records which detail that Ashley L. engaged in physical therapy for her right leg and continued to participate in physical therapy. (T. 24) citing (T. 306); (T. 1321, 2517). Worse, when ALJ Pelton asserted Ashley L. “did not attend the physical therapy prescribed,” she cited a record which notes that Ashley L. “has participated in physical therapy for over 4 weeks without improvement of pain or knee instability. Symptoms have not improved with rest, elevation or ice.” (T. 24, 1325). Put differently, ALJ Pelton ignored more Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 25 of 29
26 recent evidence, chose evidence that supported her position, and relied on cherry picked evidence. That is improper. See, e.g., Pamela P. v. Saul, No. 19-CV-575 (DJS), 2020 WL 2561106, at *5 (N.D.N.Y. May 20, 2020) (remanding the ALJ’s decision where “[a] careful review of the record reveals that the ALJ’s opinion itself cherry picks from the record to place Plaintiff’s overall mental functioning in the best possible light.”) Beyond that, ALJ Pelton did not meaningfully engage with evidence that supports Ashley L.’s claim. The record is replete with evidence that Ashley L. suffers from a lower leg injury which has severely limited her mobility even though she participates in physical therapy. See, e.g., (T. 2516) (“Her main complaint today is right ankle pain. [Ashley L.] states that [her ankle] actually started getting worse after her delivery” and “she has a constant burning tingling pain in her right foot and ankle.”); (T. 2521) (“Right lower leg: swelling, deformity[,] and laceration present . . . [d]ecreased range of motion with dorsiflexion passive and active.”); (T. 1321) (“Right ankle has burning pain to mid shin, right knee is sharp stabbing pain.”); (T. 1929) (“location of numbness is right lower leg.”). Still, ALJ Pelton claims that Ashley L. Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 26 of 29
27 “is not limited to the extent alleged by fracture with rod placement of the right leg” because Ashley L. “reported the ability to drive[.]” (T. 18). That reasoning cannot withstand any scrutiny. The Commissioner’s two possible objections cannot cure ALJ Pelton’s litany of errors. First, the Commissioner can argue that ALJ Pelton accounted for Ashely’s leg issues by finding Drs. Angelotti’s and Grier’s opinions unpersuasive and reasoning that evidence suggests greater limitations than Drs. Angelotti’s and Grier’s opinions. (T. 23, 24). Second, the Commissioner can argue that ALJ Pelton accounted for Ashely’s leg issues by fashioning an RFC that limited Ashley L. to never crawling, climbing ladders, ropes, or scaffolds, and occasionally climbing ramps or stairs, stooping, kneeling, and crouching. (T. 17). Both arguments suffer from the same two defects. First, the argument is procedurally defective because it is a post-hoc rationalization of the ALJ Pelton’s decision. And it has long been understood that reviewing courts “may not accept appellate counsel’s post hoc rationalizations for agency decisions.” Terrence F. v. Comm’r of Soc. Sec. No. 20-CV-1304 (ATB), 2022 WL 1203074 at *5 (cleaned up) (quoting Burlington Truck Lines, Inc. v. United States, 371 U.S. 156, Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 27 of 29
28 168 (1962)). Second, ALJ Pelton did not show her work. But an ALJ’s decision must create “an accurate and logical bridge from the evidence to” their “conclusion.” Shanaye S.M. v. Comm’r of Soc. Sec., No: 18-CV- 0217 (TWD), 2019 WL 1988672, at *4 (N.D.N.Y. May 6, 2019) (cleaned up). Indeed, “ALJs written decisions must be sufficiently detailed so courts can conduct an adequate review of their “findings.” John S. v. Bisignano, No. 24-CV-334 (BKS/MJK), 2025 WL 2201107, at *6 (N.D.N.Y. June 13, 2025) (cleaned up). Yet ALJ Pelton’s decision does not create the logical bridge necessary for a Court to determine that she fashioned the physical limitations she because of the Ashely leg issues. * * * To end, this Court recommends finding that substantial evidence does not support ALJ Pelton’s decision. ALJ Pelton did not meaningfully engage with the evidence surrounding Ashley L.’s need for a cane, did not identify how her Class III obesity interfered with her ability to walk, cherry picked evidence, and did not engage with evidence that supported Ashley L.’s claim. Frankly, ALJ Pelton’s decision is far too riddled with error to recommend anything but reversal. So this Court does so. Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 28 of 29
29 VII CONCLUSION WHEREFORE, based on the findings above, it is RECOMMENDED, that Ashley L.’s motion for judgment on the pleadings (Dkt. 11) be GRANTED; and if the District Court disagrees with that recommendation, it is alternatively RECOMMENDED, that the Ashley L.’s motion for judgment on the pleadings (Dkt. 11) be GRANTED because substantial evidence does not support ALJ Pelton’s decision; and it is further RECOMMENDED, that the decision of the Commissioner be REVERSED and REMANDED. In accordance with 28 U.S.C. § 636(b)(1) and Local Rule 72.1(c), the parties have 14 days within which to file written objections to the foregoing report. Such objections shall be filed with the Clerk of the Court. FAILURE TO OBJECT TO THIS REPORT WITHIN FOURTEEN DAYS WILL PRECLUDE APPELLATE REVIEW. Roldan v. Racette, 984 F.2d 85, 89 (2d Cir. 1993); 28 U.S.C. § 636(b)(1); Fed. R. Civ. P. 6(a), 6(e), 72. Dated: March 18, 2026 _____________________________ Hon. Mitchell J. Katz U.S. Magistrate Judge Case 5:25-cv-00809-MAD-MJK Document 15 Filed 03/18/26 Page 29 of 29
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