Ruiz-Zayas v. Commissioner of Social Security

UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF NEW YORK
_____________________________________
AMANDA MICHELLE R.-Z.,
Plaintiff,
v.
No. 6:24-CV-01454
COMMISSIONER OF SOCIAL SECURITY, 	(PJE)
Defendant.
_____________________________________
APPEARANCES: 	OF COUNSEL:
Olinsky Law Group 	HOWARD D. OLINSKY, ESQ.
250 South Clinton Street- Suite 210
Syracuse, New York 13202
Attorneys for plaintiff
Social Security Administration 	GEOFFREY M. PETERS, ESQ.
Office of the General Counsel
6401 Security Boulevard
Baltimore, Maryland 21235
Attorneys for defendant
PAUL J. EVANGELISTA
U.S. MAGISTRATE JUDGE
MEMORANDUM-DECISION AND ORDER1
Amanda Michelle R.-Z.2 (“plaintiff”) brings this action pursuant to 42 U.S.C.
§ 405(g) seeking review of a decision by the Commissioner of the Social Security
Administration (“the Commissioner”) denying her application for disability insurance
1 Parties consented to direct review of this matter by a Magistrate Judge pursuant to 28 U.S.C. § 636(c),
Fed. R. Civ. P. 73, L.R. 72.2(b), L.R. 72.3(b), and General Order 18. See Dkt. No. 5.
2 In accordance with guidance from the Committee on Court Administration and Case Management of the
Judicial Conference of the United States, which was adopted by the Northern District of New York in 2018
to 	better 	protect 	personal 	and 	medical 	information 	of 	non-governmental 	parties, 	this 	Report-
Recommendation and Order will identify plaintiff’s last name by initial only.
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 1 of 18

2
benefits (“DIB”). See Dkt. No. 1. Plaintiff cross-moves for the Commissioner’s decision
to 	be 	vacated 	and 	remanded 	for 	further 	proceedings. 	See 	Dkt. 	No. 	12. 	The
Commissioner cross-moves for the decision to be affirmed. 	See Dkt. No. 13.3 	Plaintiff
filed a reply. 	See Dkt. No. 14. 	For the following reasons, plaintiff’s cross-motion is
granted, the Commissioner’s cross-motion is denied, and the Commissioner’s decision is
reversed and remanded for further proceedings.
I. Background
On October 28, 2022, plaintiff filed a Title XII application for DIB benefits, alleging
a disability onset date of July 21, 2022. See id. at 76, 240-414 (See Dkt. Nos. 9-3, 9-5)5.
On March 16, 2023, the Social Security Administration (“SSA”) denied plaintiff’s claim.
See id. at 107-10 (See Dkt. No. 9-4). 	Plaintiff sought reconsideration, which the SSA
denied on October 12, 2023. See id. at 151-55 (See Dkt. No. 9-4). Plaintiff appealed and
requested a hearing. See id. at 156-57 (See Dkt. No. 9-4). On June 25, 2024, a hearing
was held before Administrative Law Judge (“ALJ”) Jennifer Smith. See id. at 33-75 (See
Dkt. No. 9-2). On July 31, 2024, the ALJ issued an unfavorable decision. See id. at 12-
32 (See Dkt. No. 9-2). 	On October 15, 2024, the Appeals Council affirmed the ALJ’s
determination, and the decision became final. See id. at 1-6 (See Dkt. No. 9-2). Plaintiff
commenced the instant action on December 2, 2024. See Dkt. No. 1.
3 This matter has been treated in accordance with General Order 18. Under that General Order, once issue
has been joined, an action such as this is considered procedurally as if cross-motions for judgement on the
pleadings have been filed pursuant to Rule 12(c) of the Federal Rules of Civil Procedure.
4 “T.” followed by a number refers to the pages of the administrative transcript. See Dkt. No. 9. Citations
to the administrative transcript refer to the pagination in the bottom, right-hand corner of the page. Citations
to the parties’ briefs refer to the pagination generated by the Court’s electronic filing program, located at
the header of each page.
5 Due to the voluminous nature of the administrative transcript, which the Commissioner uploaded to the
Court’s docket in multiple parts, in addition to the record citation, the Court includes the docket cite for
factual citations.
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 2 of 18

3
II. Legal Standards
A. Standard of Review
“In reviewing a final decision of the Commissioner, a district court may not
determine de novo whether an individual is disabled.” 	Joseph J. B. v. Comm’r of Soc.
Sec., No. 1:23-CV-652 (BKS/CFH), 2024 WL 4217371, at *1 (N.D.N.Y. Aug. 29, 2024),
report and recommendation adopted, No. 1:23-CV-652 (BKS/CFH), 2024 WL 4216048
(N.D.N.Y. Sept. 17, 2024) (citing 42 U.S.C. §§ 405(g), 1388(c)(3)); see also Wagner v.
Sec’y of Health & Human Servs., 906 F.2d 856, 860 (2d Cir. 1990). 	“Rather, the
Commissioner’s determination will only be reversed if the correct legal standards were
not applied, or it was not supported by substantial evidence.” 	Id. (citing Johnson v.
Bowen, 817 F.2d 983, 985-86 (2d Cir. 1987)); see also Berry v. Schweiker, 675 F.2d 464,
467 (2d Cir. 1982). “Substantial evidence is ‘more than a mere scintilla,’ meaning that in
the record one can find ‘such relevant evidence as a reasonable mind might accept as
adequate to support a conclusion.’” Id. (quoting Halloran v. Barnhart, 362 F.3d 28, 31 (2d
Cir. 2004) (per curiam) (citing Richardson v. Perales, 402 U.S. 389, 401 (1971))). 	“The
substantial evidence standard is a very deferential standard of review . . . [This] means
once an ALJ finds facts, we can reject [them] only if a reasonable factfinder would have
to conclude otherwise.” 	Id. (quoting Brault v. Soc. Sec. Admin., Comm’r, 683 F.3d 443,
448 (2d Cir. 2012) (per curiam)) (internal quotation marks omitted). 	“Where there is
reasonable doubt as to whether the Commissioner applied the proper legal standards,
the decision should not be affirmed even though the ultimate conclusion is arguably
supported by substantial evidence.” Id. (citing Martone v. Apfel, 70 F. Supp. 2d 145, 148
(N.D.N.Y. 1999) (citing Johnson, 817 F.2d at 986)). 	“However, if the correct legal
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 3 of 18

4
standards were applied and the ALJ’s finding is supported by substantial evidence, such
finding must be sustained ‘even where substantial evidence may support the plaintiff’s
position and despite that the court’s independent analysis of the evidence may differ from
the [Commissioner’s].’” Id. (quoting Rosado v. Sullivan, 805 F. Supp. 147, 153 (S.D.N.Y.
1992)).
B. Determination of Disability
“Every individual who is under a disability shall be entitled to a disability . . . benefit
. . . .” 	42 U.S.C. § 423(a)(1)(E). 	Disability is defined as the “inability to engage in any
substantial gainful activity by reason of any medically determinable physical or mental
impairment . . . which has lasted or can be expected to last for a continuous period of not
less than 12 months[.]” 	Id. § 423(d)(1)(A). 	“A medically-determinable impairment is an
affliction that is so severe that it renders an individual unable to continue with his or her
previous work or any other employment that may be available to him or her based upon
age, education, and work experience.” Joseph J. B., 2024 WL 4217371, at *2 (citing 42
U.S.C. § 423(d)(2)(A)). “Such an impairment must be supported by ‘medically acceptable
clinical and laboratory diagnostic techniques.’” 	Id. (citing 42 U.S.C. § 423(d)(3)).
“Additionally, the severity of the impairment is ‘based on objective medical facts,
diagnoses[,] or medical opinions inferable from [the] facts, subjective complaints of pain
or disability, and educational background, age, and work experience.’” 	Id. (quoting
Ventura v. Barnhart, No. 04-CV-9018 (NRB), 2006 WL 399458, at *3 (S.D.N.Y. Feb. 21,
2006) (citing Mongeur v. Heckler, 722 F.2d 1033, 1037 (2d Cir. 1983))).
The Second Circuit employs a five-step analysis, based on 20 C.F.R. § 404.1520,
to determine whether an individual is entitled to disability benefits:
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 4 of 18

5
First, the [Commissioner] considers whether the claimant is currently
engaged in substantial gainful activity.
If he [or she] is not, the [Commissioner] next considers whether the claimant
has a “severe impairment” which significantly limits his [or her] 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 an impairment which is
listed in Appendix 1 of the regulations. If the claimant has such an
impairment, the [Commissioner] will consider him [or her] disabled without
considering 	vocational 	factors 	such 	as 	age, 	education, 	and 	work
experience; the [Commissioner] presumes that a claimant who is afflicted
with a “listed” impairment is unable to perform substantial gainful activity.
Assuming the claimant does not have a listed impairment, the fourth inquiry
is whether, despite the claimant’s severe impairment, he [or she] has the
residual functional capacity to perform his [or her] past work.
Finally, if the claimant is unable to perform his [or her] past work, the
[Commissioner] then determines whether there is other work which the
claimant could perform . . .
Berry, 675 F.2d at 467 (spacing added). 	“If at any step a finding of disability or non-
disability can be made, the SSA will not review the claim further.” Joseph J. B., 2024 WL
4217371, at *2 (quoting Barnhart v. Thomas, 540 U.S. 20, 24 (2003)). “The plaintiff bears
the initial burden of proof to establish each of the first four steps.” Id. (citing DeChirico v.
Callahan, 134 F.3d 1177, 1180 (2d Cir. 1998) (citing Berry, 675 F.2d at 467)). 	“If the
inquiry progresses to the fifth step, the burden shifts to the Commissioner to prove that
the plaintiff is still able to engage in gainful employment somewhere.” 	Id. (citing
DeChirico, 134 F.3d at 1180 (citing Berry, 675 F.2d at 467)).
III. The ALJ’s Decision
The ALJ determined that plaintiff “last met the insured status requirements of the
Social Security Act on September 30, 2023.” 	T. at 17 (See Dkt. No. 9-2). Applying the
five-step disability sequential evaluation, the ALJ first noted that plaintiff “did not engage
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 5 of 18

6
in substantial gainful activity during the period from her alleged onset date of July 21,
2022, through her date last insured of September 30, 2023.” 	Id. (See Dkt. No. 9-2). At
step two, the ALJ found that, “[t]hrough the date last insured, [plaintiff] had the following
severe impairments: degenerative changes of the lumbar spine, degenerative changes
of the cervical spine, fibromyalgia, diabetes, [irritable bowel syndrome (“IBS”)], sleep
apnea, asthma, hypersomnia, obesity, bipolar disorder, an anxiety disorder[,] and PTSD.”
Id. (See Dkt. No. 9-2). 	At step three, the ALJ determined that, “[t]hrough the date last
insured, [plaintiff] did not have an impairment or combination of impairments that met or
medically equaled the severity of one of the listed impairments in 20 CFR Part 404,
Subpart P, Appendix 1.” Id. at 19 (See Dkt. No. 9-2).
Before reaching step four, the ALJ concluded that through the date of last insured,
plaintiff retained the residual functional capacity (“RFC”) to
perform light work6 as defined in 20 CFR 404.1567(b) except she should
not 	work 	at 	unprotected 	heights 	or 	in 	close 	proximity 	to 	dangerous
machinery or moving mechanical parts of equipment. The claimant should
not climb ladders/ropes/scaffolds, balance, as defined in the [Selected
Characteristics of Occupations (“SCO”)], kneel, crouch or crawl. She can
occasionally climb ramps/stairs and stoop. 	The claimant should have no
concentrated exposure to respiratory irritants such as dust, odors, fumes,
gases, wetness, humidity and extreme hot/cold temperatures. 	She can
understand, remember and carry out simple instructions. The claimant can
use judgment to make simple, work-related decisions. 	She can work at a
job with occasional changes in the routine work setting. She cannot perform
6 20 C.F.R. §§ 404.1567(b) and 416.967(b) provide that the physical exertion requirements for “light
work”:
involves lifting no more than 20 pounds at a time with frequent lifting or carrying of objects
weighing up to 10 pounds. Even though the weight lifted may be very little, a job is in this
category when it requires a good deal of walking or standing, or when it involves sitting
most of the time with some pushing and pulling of arm or leg controls. To be considered
capable of performing a full or wide range of light work, you must have the ability to do
substantially all of these activities. If someone can do light work, we determine that he or
she can also do sedentary work, unless there are additional limiting factors such as loss of
fine dexterity or inability to sit for long periods of time.
20 C.F.R. §§ 404.1567(b); 416.967(b).
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 6 of 18

7
work requiring a specific production rate, such as an assembly line, or work
that 	requires 	hourly quotas. 	She 	can 	have 	occasional 	contact 	with
coworkers, supervisors and the public. 	She can use the bathroom and
change positions during ordinary breaks and the lunch hour.
Id. at 21 (See Dkt. No. 9-2). At step four, the ALJ determined that plaintiff “has no past
relevant work.” Id. at 25 (See Dkt. No. 9-2). Before reaching step five, the ALJ concluded
that the “[t]ransferability of job skills is not an issue because the claimant does not have
past relevant work.” Id. (See Dkt. No. 9-2). At step five, the ALJ determined that “[t]hrough
the date last insured, considering the claimant’s age, education, work experience, and
residual functional capacity, there were jobs that existed in significant numbers in the
national economy that the claimant could have performed.” Id. (See Dkt. No. 9-2). The
ALJ concluded that plaintiff “was not under a disability, as defined in the Social Security
Act, at any time from July 21, 2022, the alleged onset date, through September 30, 2023,
the date last insured.” Id. at 26 (See Dkt. No. 9-2).
IV. Discussion
A. The Parties’ Arguments
Plaintiff argues that the ALJ’s RFC determination is not supported by substantial
evidence for two reasons. See Dkt. No. 12 at 14-21. 	First plaintiff argues that the ALJ
failed to apply the supportability and consistency factors to state consultative examiner
Dr. Grassl’s opinion. 	See id. at 14-18. 	Plaintiff notes that the ALJ “briefly mentions the
opinion of Dr. Grassl, finding it ‘less persuasive’ because the opinion was rendered
‘several years prior to the period in question.’” Id. at 15 (citing T. at 24). However, plaintiff
argues that the ALJ’s decision does not contain “any discussion of the supportability or
consistency factors.” 	Id. 	Plaintiff further argues that even though Dr. Grassl’s opinion
was issued prior to the alleged onset date, “[t]he Commissioner’s regulations require that
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 7 of 18

8
ALJ’s evaluate all opinion evidence within the record.” 	Id. at 16 (citing 20 CFR §
404.1520c(b)). Second, plaintiff argues that the ALJ’s RFC determination fails to account
the 	limitations 	her 	sleep 	apnea 	causes, 	hypersomnia, 	and 	IBS, 	despite 	the ALJ
determining that these conditions were severe impairments. 	See id. at 18-21. 	More
specifically, plaintiff maintains that (1) the ALJ failed to discuss “any restrictions related to
[her] hypersomnia” or explain how “normal breaks would account for her uncontrolled
IBS[,]” (2) none of the medical opinions the ALJ relied upon consider her hypersomnia or
IBS, and (3) ALJ did not account for “the constant exhaustion caused by [her] . . .
hypersomnia and sleep apnea.” Id. at 19.
The Commissioner argues that the ALJ’s decision is supported by substantial
evidence and should be affirmed. 	See Dkt. No. 13 at 7-18. 	In response to plaintiff’s
arguments, the Commissioner contends that “[b]ecause Dr. Grassl’s report significantly
predated and thus was not probative of the relevant period, the ALJ had no requirement
to discuss the supportability and consistency of the opinion.” 	Id. at 9. Alternatively, the
Commissioner argues that even if the ALJ had considered Dr. Grassl’s opinion, the issue
is moot because Dr. Grassl opined that plaintiff’s mental limitations were less restrictive
than those assigned by the ALJ. 	See id. at 10. 	The Commissioner also argues that
although 	the 	ALJ 	determined 	IBS, 	sleep 	apnea, 	and 	hypersomnia 	were 	severe
impairments, the ALJ is not required to assign any corresponding functional limitations for
these conditions as part of the RFC determination. See id. at 11-12 (citing Christine M.
v. Saul, No. 8:18-CV-1358 (DJS), 2019 WL 5307316, at *3 (N.D.N.Y. Oct. 21, 2019)). The
Commissioner maintains that the evidence supporting plaintiff’s argument concerning her
IBS, sleep apnea, and hypersomnia is comprised mostly of subjective complaints without
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 8 of 18

9
any further support. See id. at 13, 15. The Commissioner further argues that the medical
opinions of record consider these conditions and support the ALJ’s RFC determination.
See id. at 13-14, 16-17.
In reply plaintiff argues that (1) the case law cited the Commissioner cites does not
apply the current version of the regulations, (2) not all parts of Dr. Grassl’s opinion were
less restrictive than the ALJ’s RFC determination, and (3) the Commissioner’s arguments
are nonresponsive to the claims plaintiff raised in her cross-motion. 	See generally Dkt.
No. 14.
B. Consideration of Medical Evidence
“An ALJ is required to consider all of the medical opinion evidence in the record.”
Crane v. Comm’r of Soc. Sec. Admin., No. 22-CV-7133 (JMW), 2024 WL 4569417, at *14
(E.D.N.Y. Oct. 24, 2024) (quoting Hahn v. Saul, 20-CV-6124 (KAM), 2023 WL 4975970,
at *4, (E.D.N.Y. Aug. 3, 2023) (citing 20 C.F.R. § 404.1520c(b))) (“We will articulate in our
determination or decision how persuasive we find all of the medical opinions and all of
the prior administrative medical findings in your case record.”). “Regardless of its source,
the ALJ must evaluate every medical opinion in determining whether a claimant is
disabled under the Social Security Act.” Berry v. Comm’r of Soc. Sec., No. 22-CV-7615
(PKC), 2024 WL 1382765, at *5 (E.D.N.Y. Mar. 21, 2024) (quoting Williams v. Kijakazi,
No. 20-CV-8469 (JLC), 2022 WL 799478, at *12 (S.D.N.Y. Mar. 16, 2022) (quoting Pena
ex rel. E.R. v. Astrue, No. 11-CV-1787 (KAM), 2013 WL 1210932, at *14 (E.D.N.Y. Mar.
25, 2013))); see 20 C.F.R. §§ 404.1527(c), 416.927(c).
“However, [a]n ALJ need not recite every piece of evidence that contributed to the
decision, so long as the record permits [the Court] to glean the rationale of an ALJ’s
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 9 of 18

10
decision.” Tina S. v. Comm’r of Soc. Sec., No. 1:21-CV-219 (JLS), 2023 WL 4286039, at
*6 (W.D.N.Y. June 29, 2023) (quoting Cichocki V. Astrue, 729 F.3d 172, 178 n.3 (2d Cir.
2013)) (internal quotation marks omitted). 	“Failure to discuss medical opinion evidence
may be harmless error.” 	Id. (citing Zabala v. Astrue, 595 F.3d 402, 409 (2d Cir. 2010))
(“[W]here application of the correct legal principles to the record could lead [only to the
same] conclusion, there is no need to require agency reconsideration.”); see Jessica Lynn
J. v. Comm’r of Soc. Sec., 645 F. Supp. 3d 128, 134 (W.D.N.Y. 2022) (“failure to discuss
and/or weigh a medical opinion is not per se remandable error but may be found harmless
error.”).
1. Dr. Grassl
Dr. Grassl is a state consultative medical examiner who examined plaintiff on
August 13, 2020. See T. at 997-1000 (See Dkt. No. 9-7). Plaintiff reported to Dr. Grassl
that she (1) slept twelve-to-sixteen hours per day; (2) had a normal appetite; and
(3) bathed one day per week due to lack of motivation. See id. at 997, 999 (See Dkt. No.
9-7). 	Plaintiff 	stated 	that 	her 	“[d]epressive 	symptomatology 	ha[d] 	improved 	with
treatment, but she still experience[d] loss of usual interest and social withdrawal.” Id. at
997(See Dkt. No. 9-7). “She denied suicidal or homicidal ideation, intent, or plan in the
past 30 days.” 	Id. (See Dkt. No. 9-7). 	Plaintiff stated that “her last manic episode was
approximately a year ago with increased need for sleep, distractibility, elevated mood,
flight of ideas, and excessive involvement in pleasurable activities.” Id. (See Dkt. No. 9-
7). 	Plaintiff “denied symptoms of formal thought disorder” and “endorsed short-term
memory deficits and concentration difficulties.” Id. (See Dkt. No. 9-7).
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 10 of 18

11
Dr. Grassl stated that although plaintiff “endorsed exposure to trauma and
hypervigilance, she did not meet full criteria for PTSD.” T. at 997 (See Dkt. No. 9-7). Dr.
Grassl diagnosed plaintiff with bipolar I disorder and unspecified anxiety disorder. 	See
id. at 999 (See Dkt. No. 9-7). Dr. Grassl opined that plaintiff was
moderately limited in her ability to sustain concentration and perform a task
at a consistent pace, sustain an ordinary routine and regular attendance at
work, and regulate emotions, control behavior, and maintain well being. No
evidence of limitation in her ability to understand, remember, and apply
simple 	directions 	and 	instructions, 	understand, 	remember, 	and 	apply
complex directions and instructions, use reason and judgment to make
work-related decisions, interact adequately with supervisors, coworkers,
and the public, maintain personal hygiene and appropriate attire, or be
aware of normal hazards and take appropriate precautions. Difficulties are
caused by psychiatric problems.
Id. (See Dkt. No. 9-7).
In the hearing decision on appeal, the ALJ concluded that Dr. Grassl’s opinion was
less persuasive because it was “rendered several years prior to the period in question.
However, it is noteworthy that . . . psychologist Grassl found no more than a moderate
limitation in any area.” T. at 24 (See Dkt. No. 9-2). As stated above, the plaintiff argues
that the Commissioner committed reversible error by failing to address the supportability
and consistency factors regarding Dr. Grassl’s opinion. 	See Dkt. No. 12 at 14-18. 	In
response, the Commissioner argues that Dr. Grassl’s opinion is not probative of plaintiff’s
conditions because her opinion was proffered “almost two years” prior to the alleged onset
date. Dkt. No. 13 at 9. The Commissioner alternatively argues that Dr. Grassl’s opinion
of moderate or no mental limitations was less restrictive than the ALJ’s RFC finding and
plaintiff’s argument is therefore moot. 	See id. at 10. 	The Court concludes that the
Commissioner’s arguments lack merit.
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 11 of 18

12
The undersigned agrees with the Commissioner that Dr. Grassl issued her opinion
in August 2020, approximately two years prior to plaintiff’s alleged onset date. See T. at
76, 999 (See Dkt. Nos. 9-3, 9-7). However, the undersigned disagrees that this fact alone
renders 	Dr. 	Grassl’s 	opinion 	irrelevant 	to 	the 	analysis 	of 	plaintiff’s 	mental 	health
conditions, such that the ALJ did not have to consider the opinion.7 	Here, Dr. Grassl
opined on plaintiff’s mental health symptoms and limitations stemming from plaintiff’s
bipolar disorder, anxiety disorder, and PTSD. 	See T. at 997-1000 (See Dkt. No. 9-7).
These are the same conditions that the ALJ determined were severe impairments and the
same or similar conditions, symptoms, and limitations that Dr. Komareth and Dr. Lyons
analyzed in their medical source statements.8 	See id. at 17, Compare T. at 997-1000,
with 3892-96, and 4880-84 (See Dkt. Nos. 9-2, 9-7, 9-13, 9-20).
The SSA is required to develop a “complete medical history for at least the 12
months preceding the month in which” a plaintiff files an application for benefits “unless
7 The Court notes that the Commissioner does not argue that Dr. Grassl’s opinion is stale. “[A]n ALJ should
not rely on ‘stale’ [medical source] opinions . . . .” Steve P. v. Comm’r of Soc. Sec., No. 19-CV-492 (MWP),
2021 WL 307566, at *5 (W.D.N.Y. Jan. 29, 2021) (quoting Robinson v. Berryhill, No. 1:17-CV-362 (LJV/JJM),
2018 WL 4442267, at *4 (W.D.N.Y. Sept. 17, 2018)). 	“In general, medical source opinions that are
conclusory, stale, and based on an incomplete medical record may not be substantial evidence to support
an ALJ finding.” Michael R. D. v. Comm’r of Soc. Sec., No. 1:21-CV-215 (JLS), 2023 WL 3869022, at *4
(W.D.N.Y. June 7, 2023) (quoting Camille v. Colvin, 104 F. Supp. 3d 329, 343 (W.D.N.Y. 2015), aff’d, 652
F. App’x 25 (2d Cir. 2016) (summary order)) (internal quotation marks omitted). 	“Medical opinions are
rendered ‘stale’ by a ‘new significant diagnosis’ or ‘significant deterioration’ in the plaintiff’s condition.”
Angele J. W. v. Comm’r of Soc. Sec., No. 6:23-CV-824 (BKS/CFH), 2024 WL 4204301, at *5 (N.D.N.Y. July
24, 2024), report and recommendation adopted, No. 6:23-CV-824 (BKS/CFH), 2024 WL 4204017 (N.D.N.Y.
Sept. 16, 2024) (quoting Benitez v. Comm’r of Soc. Sec., No. 23-CV-1327 (ARL), 2024 WL 1332612, at *8
(E.D.N.Y. Mar. 28, 2024) (quoting Andrea G. v. Comm’r of Soc. Sec., No. 5:20-CV-1253 (TWD), 2022 WL
204400, at *7 (N.D.N.Y. Jan. 24, 2022))); see Carney v. Berryhill, No. 16-CV-269 (FPG), 2017 WL 2021529,
at *6 (W.D.N.Y. May 12, 2017) (“[A] medical opinion may be stale if it does not account for the [plaintiff's]
deteriorating condition.”). The passage of time does not render a medical source opinion “stale” as long as
“the subsequent evidence does not undermine [the opinion evidence].” Steve P., 2021 WL 307566, at *5
(quoting Hernandez v. Colvin, No. 15-CV-6764 (CJS), 2017 WL 2224197, at *9 (W.D.N.Y. May 22, 2017)
(citing Camille v. Colvin, 652 F. App’x 25, 28 n.4 (2d Cir. 2016) (summary order) (additional citation
omitted))).
8 Although the ALJ rejected Dr. Komareth’s and Dr. Lyons’ opinions as unpersuasive, Dr. Komareth and
Dr. Lyons reviewed the same conditions and symptoms as Dr. Grassl, and the ALJ’s rejection of their
opinions was used to determine plaintiff’s RFC. See T. at 24 (See Dkt. No. 9-2).
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 12 of 18

13
there is a reason to believe that development of an earlier period is necessary or unless
[the plaintiff states] that [their] disability began less than 12 months before [they] filed
[their] application.” 20 C.F.R. § 404.1512(b)(1). “For applications for [DIB], as here, the
relevant period is the alleged disability onset date to the date last insured.” 	Crespo v.
Comm’r of Soc. Sec., No. 3:18-CV-0435 (JAM), 2019 WL 4686763, at *3 (D. Conn. Sept.
25, 	2019) 	(citing 	20 	C.F.R. 	§§ 	404.1512(b)(1), 	404.1512(b)(1)(ii)). 	Generally,
“[c]onsideration of evidence outside the relevant periods of disability . . . is not afforded
significant or convincing weight when reviewing whether an ALJ's conclusions were
supported by substantial evidence.” 	Anderson v. Comm’r of Soc. Sec. Admin., No. 22-
CV-1509 (JMW), 2025 WL 660330, at *12 (E.D.N.Y. Feb. 28, 2025) (citing Mauro v.
Berryhill, 270 F. Supp. 3d 754, 762 (S.D.N.Y. 2017)).
However, ALJs are permitted to and “regularly review” evidence created prior to
the filing date, as it is “often relevant” to the claims period. 	Thomas v. Comm’r of Soc.
Sec., No. 1:18-CV-839 (JJM), 2020 WL 548394, at *3 (W.D.N.Y. Feb. 4, 2020) (quoting
Hussain v. Comm’r of Soc. Sec., No. 13 CIV. 3691 (AJN-GWG), 2014 WL 4230585, at
*12 (S.D.N.Y. Aug. 27, 2014), report and recommendation adopted, No. 13-CV-3691
(AJN-GWG), 2014 WL 5089583 (S.D.N.Y. Sept. 25, 2014)) (“ALJs regularly review prior
evidence for the purpose of considering an open application, as such evidence is often
relevant to the claimant’s medical condition for the period in which benefits are claimed.”).
“In fact, there are many instances where an ALJ must consider such prior evidence to
properly assess the severity of the claimant’s medical condition during the open
application period.” 	Id. 	“[E]vidence from before or after the relevant time period often
provides necessary context for a disability claim and, if so, an ALJ cannot simply ignore
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 13 of 18

14
it.” Angele J. W., 2024 WL 4204301, at *5 (quoting Cheri Lee H. v. Comm’r of Soc. Sec.,
No. 5:19-CV-10 (DNH), 2020 WL 109007, at *5 (N.D.N.Y. Jan. 9, 2020) (“For instance, if
plaintiff’s evidence suggesting that she suffered frequent migraines (at least before the
relevant time period) stood uncontested in the record, it might well be inappropriate for
the ALJ to ignore it or to reject it out of hand.”); Norman v. Astrue, 912 F. Supp. 2d 33, 82
n.74 (S.D.N.Y. 2012) (citation omitted) (“[T]he mere absence of contemporaneous
medical evidence of a disabling condition during the relevant time period does not
necessarily preclude a finding of disability.”); Cf. Robert V. v. Kijakazi, No. 3:21-CV-377
(MPS), 2022 WL 4536838, at *3 (D. Conn. Sept. 28, 2022) (concluding that the ALJ did
not overlook evidence regarding plaintiff’s neurologic and cardiac conditions when there
was “no indication that the evidence from outside of the relevant period reflects Plaintiff's
condition during the relevant period.”).
Accordingly, the undersigned concludes that although Dr. Grassl’s opinion was
proffered prior to plaintiff’s alleged date of onset, the conditions and symptoms she
reviewed were the same as the conditions and symptoms the other medical sources
reviewed during the relevant period; therefore, Dr. Grassl’s opinion is relevant to the ALJ’s
RFC analysis and should have been addressed. See Angele J. W., 2024 WL 4204301,
at *5; Thomas, 2020 WL 548394, at *3; Garcia Medina v. Comm’r of Soc. Sec., No. 17-
CV-6793-JWF, 2019 WL 1230081, at *2 (W.D.N.Y. Mar. 15, 2019) (citation omitted)
(“While the ALJ may have had sound arguments to discredit some of these opinions –
either because they were from non-acceptable medical sources, were not particularly
helpful, or came before the alleged onset date – they were relevant at the very least and
she should have at least addressed them.”).
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 14 of 18

15
Furthermore, the undersigned notes the Commissioner’s reliance on Simpson in
support of his arguments. 	See Dkt. No. 13 at 9-10 (citing Simpson v. Comm’r of Soc.
Sec., No. 24-1104, 2025 WL 1156973, at *2 (2d Cir. Apr. 21, 2025) (summary order)). Yet,
the facts in Simpson differ from the present matter. 	In Simpson, the Second Circuit
affirmed an ALJ’s decision that rejected a treatment note from one of the plaintiff’s medical
providers because the treatment note was dated 4.5 years before the plaintiff’s claimed
onset date. Simpson, 2025 WL 1156973, at *2. The Court explained that even if the ALJ
had credited the treatment note as a medical opinion, there was “‘no reasonable
likelihood’ that the note ‘would have changed the ALJ’s determination.’” Simpson, 2025
WL 1156973, at *2 (quoting Zabala v. Astrue, 595 F.3d 402, 410 (2d Cir. 2010)). 	Here,
Dr. Grassl rendered her opinion approximately two years prior to plaintiff’s alleged onset
date, well before the 4.5 years of the treatment record in Simpson. See T. at 997-1000
(See Dkt. No. 9-7). Additionally, as will be discussed below, the ALJ’s consideration of
Dr. Grassl’s opinion may change the RFC determination.
In passing, the ALJ rejected Dr. Grassl’s opinion because Dr. Grassl found “no
more than a moderate limitation in any area.” 	T. at 24 (See Dkt. No. 9-2). 	The
Commissioner argues that this finding renders plaintiff’s argument moot because the ALJ
determined plaintiff suffered from more restrictive limitations than Dr. Grassl. 	See Dkt.
No. 13 at 10. The Commissioner’s argument is factually incorrect.
As stated above, the ALJ determined that plaintiff can “understand, remember and
carry out simple instructions”; “use judgment to make simple, work-related decisions”;
“work at a job with occasional changes in the routine work setting”; and “have occasional
contact with coworkers, supervisors and the public.” T. at 21 (See Dkt. No. 9-2). The ALJ
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 15 of 18

16
also determined that plaintiff “cannot perform work requiring a specific production rate,
such as an assembly line, or work that requires hourly quotas.” 	In addition to these
abilities and limitations, Dr. Grassl opined that the plaintiff was also moderately limited in
her ability to have “regular attendance at work, and regulate emotions, control behavior,
and maintain well-being.” T. at 999 (See Dkt. No. 9-7). The ALJ did not address any of
these 	additional 	limitations 	set 	forth 	by 	Dr. 	Grassl 	when 	formulating 	her 	RFC
determination. 	See T. at 24 (See Dkt. No. 9-2). As the ALJ did not determine whether
these additional limitations affect plaintiff’s RFC, judicial review is frustrated, and remand
is necessary for the ALJ to render a determination in the first instance. See Kaliegh O. v.
Comm’r of Soc. Sec., No. 5:19-CV-940 (TWD), 2020 WL 5751171, at *5 (N.D.N.Y. Sept.
25, 2020) (citing Bartrum v. Astrue, 32 F. Supp. 3d 320, 331 (N.D.N.Y. 2012)) (“[I]t is the
ALJ’s responsibility to make factual findings in the first instance, not this Court’s.”);
Rodgers v. Saul, No. 3:19-CV-653 (JCH), 2020 WL 13551952, at *4 (D. Conn. May 28,
2020) (noting that “it is the role of the ALJ, the factfinder in the first instance” to consider
the evidence); Williams v. Astrue, No. 10-CV-5521 (CBA), 2012 WL 3096694, at *1
(E.D.N.Y. July 30, 2012) (“[I]t is for the Social Security Administration, not this Court, to
weigh conflicting evidence in the first instance and fully develop the record[.]”).
Accordingly, the Court concludes that remand is necessary for the ALJ to consider
Dr. Grassl’s opinion. 	See Joseph J. B. v. Comm’r of Soc. Sec., No. 1:23-CV-652
(BKS/CFH), 	2024 	WL 	4217371, 	at 	*1 	(N.D.N.Y. 	Aug. 	29, 	2024), 	report 	and
recommendation adopted, No. 1:23-CV-652 (BKS/CFH), 2024 WL 4216048 (N.D.N.Y.
Sept. 17, 2024) (quoting Malcolm M. v. Comm’r of Soc. Sec., No. 1:17-CV-986 (CFH),
2019 WL 187725, at *4 (N.D.N.Y. Jan. 14, 2019) (first citing Martone v. Apfel, 70 F. Supp.
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 16 of 18

17
2d 145, 150 (N.D.N.Y. 1999), then citing 20 C.F.R. §§ 404.1545, 416.945))) (“RFC
describes what a claimant is capable of doing despite his or her impairments, considering
all relevant evidence, which consists of physical limitations, symptoms, and other
limitations beyond the symptoms.”); 20 C.F.R. §§ 416.920c(c)(1)-(2)
The Court will not address plaintiff’s remaining arguments which the ALJ may
consider on remand. See Devra B. B. v. Comm’r of Soc. Sec., No. 6:20-CV-643 (BKS),
2021 WL 4168529, at *8 (N.D.N.Y. Sept. 14, 2021) (“Because the Court has determined
that remand is required, the Court does not reach Plaintiff's remaining arguments.”);
Shields v. Astrue, No. 11-CV-2088 (FB), 2012 WL 1865505, at *3 (E.D.N.Y. May 22, 2012)
(“In light of the decision to remand this case with instructions to consider new evidence
on Shields's cardiac condition, it is not necessary to address this argument.”); Mary S. v.
Kijakazi, No. 3:21-CV-1095 (RMS), 2022 WL 4074536, at *17 (D. Conn. Aug. 26, 2022)
(quoting Lockwood v. Comm’r of Soc. Sec. Admin., 914 F.3d 87, 94 (2d Cir. 2019) (“[S]ince
the ‘case must return to the agency either way for the reasons already given . . . the
Commissioner will have the opportunity on remand to obviate th[ese] dispute[s] altogether
by’ addressing the remaining arguments on remand.”); Annunziato v. Berryhill, No. 3:17-
CV-606 (JAM), 2019 WL 156934, at *4 (D. Conn. Jan. 10, 2019) (“The ALJ shall also
consider plaintiff's remaining arguments on remand.”).
V. Conclusion
WHEREFORE, for the reasons stated herein, it is hereby:
ORDERED, that plaintiff’s cross-motion (Dkt. No. 12) is GRANTED; and it is further
ORDERED, that the Commissioner’s cross-motion (Dkt. No. 13) is DENIED; and
it is further
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 17 of 18

18
ORDERED, that the Commissioner’s decision is REVERSED, and the matter
REMANDED for further proceedings; and it is
ORDERED, that the Clerk serve a copy of this Memorandum-Decision & Order on
all parties in accordance with Local Rules.
IT IS SO ORDERED.
Date: 	March 9, 2026
Albany, New York
Case 6:24-cv-01454-PJE Document 15 Filed 03/09/26 Page 18 of 18