Case Name in Social Security Case - Unavailable

CHRISTIAN W.,1
-vs-
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
Plaintiff, 	DECISION AND ORDER
1:24-CV-00461-MAV
COMMISSIONER OF SOCIAL SECURITY,
Defendant.
INTRODUCTION
On May 13, 2024, Christian W. ("Plaintiff') filed this action pursuant to 42
U.S.C. § 405(g), seeking judicial review of the Commissioner of the United States
Social 	Security Administration 's 	("Commissioner") 	denial 	of his 	application 	for
Disability Insurance Benefits ("DIE"). ECF No. 1. Plaintiff moved for judgment on
the pleadings pursuant to Rule 12(c), ECF No. 8, and the Commissioner cross-moved
for judgment on the pleadings, ECF No. 12.
For 	the 	reasons 	set forth 	below, 	Plaintiffs 	motion 	for 	judgment 	on the
pleadings [ECF No. 8] is granted, and the Commissioner's motion for judgment on
the pleadings [ECF No. 12] is denied.
PROCEDURAL HISTORY
The Court assumes the reader's familiarity with the facts and procedural
history in this case, and therefore addresses only those facts and issues which bear
1 The Court's Standing Order issued on November 18, 2020, directs that , "in opinions filed pursuant
to .. . 42 U .S.C. § 405(g), in the United States District Court for the Western District of New York, any
non-government party will be identified and referenced solely by first name and last initial."
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directly on the resolution of the motions presently before the Court.
I. Plaintiffs Application
Plaintiff filed his application for DIE on July 14, 2021. Administrative Record
("AR") at 151-152. 2 He alleged a disability onset date of January 15, 2021. AR at 152.
The Social Security Administration ("SSA") denied his DIE claim on November 9,
2021 and denied on reconsideration on March 30, 2022. AR at 161, 178.
II. Plaintiffs Hearing Before the ALJ
After the Commissioner denied his application at the initial level and on
reconsideration, Plaintiff appeared with counsel via telephone conference (due to
COVID-19 restrictions) on February 28, 2023, for a hearing before an Administrative
Law Judge ("ALJ"). AR at 110-150.
Plaintiff testified that his doctors told him to exercise and to wear compression
stockings for his diabetes and heart disease. AR at 	124. He wore 	compression
stockings but lacked the energy to go to the gym. AR at 127. After he stopped working,
he started "feeling some pressure in [his] chest" and had surgery for a stent to be
placed in his heart. AR at 128. Plaintiff said that no "limitations [had] been put on
[him] by [his] providers." AR at 128. He had shortness of breath with exertion,
including walking. AR at 128-129. He would lie down for at least two hours during
the day and would elevate his legs. AR at 129-130. He got swelling in his legs "here
and there," a "couple times a week." AR at 131, 132.
2 The page references from the transcripts are to the bates numbers inserted by the Commissioner,
not the pagination assigned by the Court's CM/ECF electronic filing system.
2
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Vocational Expert ("VE") Robert Paterwic also testified and said that Plaintiff
had transferrable skills from his past relevant work. AR at 137-138 . His skills would
transfer to jobs of assembler and electronic motor assembler, which required at least
six hours of standing a day, but would allow for frequent postural changes from
sitting to standing. AR at 142-146.
III. The ALJ's Decision
On April 4, 2023, the ALJ issued a decision finding that Plaintiff was not
disabled, and therefore did not qualify for DIE. AR at 94-104.
At the outset, the ALJ found that Plaintiff met the insured status requirements
for DIB3 through December 31, 2025, and had not engaged in substantial gainful
activity 	since 	the 	alleged 	onset 	date. 	AR 	at 	96. 	Then, 	at 	step 	two 	of 	the
Commissioner's "five-step, sequential evaluation process," 4 the ALJ determined that
3 Claimants must meet the insured status requirements of the Social Security Act to be eligible for
DIB. See 42 U.S . C. § 423(c); 20 C.F.R. § 404.130.
4 In addition to the insured status requirements for DIB benefits, the Social Security Administration
has outlined a "five-step, sequential evaluation process " that an ALJ must follow to determine whether
a claimant has a "disability" under the law:
(1) whether the claimant is currently engaged in substantial gainful activity; (2)
whether the claimant has a severe impairment or combination of impairments; (3)
whether the impairment meets or equals the severity of the specified impairments in
the Listing of Impairments; (4) based on a "residual functional capacity" assessment,
whether the claimant can perform any of his or her past relevant work despite the
impairment; and (5) whether there are significant numbers of jobs in the national
economy that the claimant can perform given the claimant's residual functional
capacity, age, education, and work experience .
McIntyre v. Colvin, 758 F . 3d 146, 150 (2d Cir . 2014); citing, inter alia, 20 C.F.R. § 404.1520(a)(4)(i)-
(v), § 416.920(a)(4)(i)-(v)). The claimant bears the burden of proof for the first four steps of the process.
42 U.S.C . § 423(d)(5)(A); Melville v. Apfel, 198 F.3d 45, 51 (2d Cir. 1999). At step five, the burden shifts
to the Commissioner to demonstrate that there is other work in the national economy that the claimant
can perform. Poupore v. Astrue, 566 F . 3d 303, 306 (2d Cir. 2009).
3
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Plaintiff had 	the 	following 	severe 	impairments: 	obesity, 	disorder 	of the 	spme,
diabetes, coronary artery disease status post stent placement, soft tissue injury, and
disorder of the muscle, ligament, and fascia. AR at 96.
At step three, the ALJ found that 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 C.F.R. Part 404, Subpart P, Appendix 1. AR at 97.
Before proceeding to step four, the ALJ determined that Plaintiff had the
residual functional capacity 5 ("RFC") to perform light work as defined in 20 C.F.R.
§ 404.1567(b),, except that Plaintiff could never climb ladders, ropes, or scaffolds, and
could only occasionally climb ramps and stairs. AR at 98. He required "the option to
frequently shift between sitting and standing." AR at 98.
At step four of the sequential evaluation, the ALJ found that Plaintiff was not
able to perform any of his past relevant work, but acquired transferable skills from
his past relevant work. AR at 102. The ALJ determined that considering Plaintiffs
age, education, work experience, and RFC, there were jobs that exist in significant
numbers in the national economy that Plaintiff could perform, including an assembler
and electronic motor assembler. AR at 102-103. Therefore, the ALJ found that
Plaintiff was not disabled, and not entitled to DIB payments. AR at 103-104.
On April 19, 2024, the Appeals Council denied Plaintiffs request to review the
ALJ's decision. AR at 1-7. The ALJ's decision thus became the "final decision" of the
5 "Residual functional capacity" ("RFC") means the most that the claimant can still do in a work
setting despite the limitations caused by the claimant's impairments. 20 C.F.R. § 404.1545.
4
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Commissioner. See Perez v. Chater, 77 F.3d 41, 44 (2d Cir . 1996) (citing 20 C.F.R.
§ 404.981) ("[I]f the Appeals Council denies review , the ALJ's decision becomes the
[Commissioner]'s final decision.").
LEGAL STANDARD
Under 42 U.S .C. § 423(d), a claimant is disabled and entitled to DIE if he or
she is 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 has lasted or can be expected to last for a continuous period of not less than 12
months ."
Where an individual's a pplication for DIE has been denied, 42 U.S.C. § 405(g)
defines the process and scope of judicial review of the Commissioner's final decision.
The fourth sentence of§ 405(g) authorizes the reviewing court to enter "a judgment
affirming, modifying, or reversing the decision of the Commissioner . . . with or
without remanding the cause for a rehearing." The sixth sentence authorizes the
reviewing court to "order additional evidence to be taken before the Commissioner ..
. upon a showing that there is new evidence which is material and that there is good
cause 	for 	the 	failure 	to 	incorporate 	such 	evidence 	into 	the 	record 	in 	a 	prior
proceeding." Tirado v. Bowen, 842 F.2d 595, 597 (2d Cir. 1988) (discussing§ 405(g)).
"The entire thrust of judicial review under the disability benefits law is to
ensure a just and rational result between the government and a claimant, without
substituting a court 's judgment for that of the [Commissioner], and to reverse an
administrative 	determination only when it 	does 	not 	rest 	on 	adequate findings
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sustained by evidence having rational probative force." Williams v. Bowen, 859 F.2d
255, 258 (2d Cir. 1988) (internal citation and quotation marks omitted). Therefore, it
is not the reviewing court's function to determine de nova whether the claimant is
disabled . Brault v. 	Soc. 	Sec. Admin., Comm'r, 683 F.3d 443, 447 (2d Cir. 2012).
Rather, the reviewing court must first determine "whether the Commissioner applied
the correct legal standard[s] ." Tejada v. Apfel, 167 F.3d 770, 773 (2d Cir. 1999).
Provided the 	correct 	legal standards 	are 	applied, 	the 	district 	court 's 	review 	is
deferential: 	a finding by the 	Commissioner is "conclusive" if it is supported by
"substantial evidence." 42 U.S.C. § 405(g).
"Whatever the meaning of 'substantial' in other contexts , the threshold for such
evidentiary sufficiency is not high." Biestek v. Berryhill, 587 U.S. 97, 103 (2019)
(noting that the phrase "substantial evidence" is a term of art used in reviewing
administrative agency decisions to signify evidence that amounts to "more than a
mere scintilla"). Thus, once anALJ finds facts, a reviewing court can reject those facts
"only if a reasonable factfinder would have to conclude otherwise ." Brault , 683 F . 3d
at 448. Yet , although "the evidentiary threshold for the substantial evidence standard
is not high, ... [it] is also not merely hortatory: [i]t requires relevant evidence which
would lead a reasonable mind to concur in the ALJ's factual determinations." Colgan
v. Kijakazi, 22 F.4th 353, 359 (2d Cir. 2022) (internal quotation marks omitted).
DISCUSSION
Plaintiff raises three issues in his motion for judgment on the pleadings . First,
he argues that the ALJ's decision was not based on substantial evidence because the
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VE did not testify that the jobs identified existed in significant numbers with the
limitations in the RFC. ECF No. 8 at 18-20. Second, Plaintiff argues that the ALJ
failed to address the treating source opinion that Plaintiff should elevate his legs.
ECF No. 8 at 20-21. Third, Plaintiff argues that the ALJ acted as her own medical
expert because she did not have an opinion from after Plaintiffs heart surgery and
did not adequately account for the swelling in his legs. ECF No. 8 at 21-25.
In response, the Commissioner argues that the ALJ's decision is supported by
substantial evidence. ECF No. 12-1 at 9-11. The Commissioner contends that the
opinion regarding elevating Plaintiffs legs was not a medical source statement, so
the ALJ was not required to discuss it, and the ALJ adequately discussed Plaintiffs
leg swelling. ECF No. 12-1 at 11-12. The Commissioner reads the VE's testimony
differently than Plaintiff does and concludes that the VE testified that the numbers
of jobs available encompassed all the limitations in the RFC. ECF No. 12-1 at 12-13.
The Court begins with Plaintiffs third argument because ofits conclusion that
remand is necessary on that issue.
1. 	The ALJ needed a medical opinion to assess the limitations resulting
from Plaintiffs heart disease.
Plaintiff argues that the ALJ improperly interpreted Plaintiffs cardiac test
results herself without the aid of a medical opinion, as the medical opinions were all
rendered before 	Plaintiffs diagnosis 	and heart surgery. 	ECF No. 	8 at 22. 	The
Commissioner does not respond to this argument. The Court agrees with Plaintiff.
Where there are '"no obvious gaps in the administrative record"' and "'where
the ALJ already possess[es] a complete medical history,"' a medical source opinion to
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"interpret the raw medical data to assess Plaintiffs RFC" may not be necessary.
Robert W 	v. 	Comm'r of Soc. 	Sec., No. 23-CV-688-FPG, 2026 WL 2858538, at *4
(W.D.N.Y. Sept. 23, 2026) (quoting Clark v. Comm 'r of Soc. Sec. , No. 18-CV-0509,
2019 WL 3886723, at *6 (W.D.N.Y. Aug. 19, 2019)). Indeed, if an ALJ can reach "an
informed decision based on 	substantial evidence 	without " an opinion from 	the
claimant's treating physician, remand is not required. Russ v. Comm'r of Soc. Sec.,
582 F . Supp. 3d 151, 163 (S.D.N.Y. 2022).
Here, the ALJ could not have made an informed decision regarding Plaintiffs
cardiology records without a medical opinion, so remand is required. The ALJ had an
opinion from a non-examining medical consultant from November 2021 , AR at 156,
from another non-examining consultant from March 2022, AR at 171-173, and from
a consultative examiner from October 2021, AR at 616-616. The three opinions were
from before Plaintiffs heart disease was discovered in July 2022. See AR at 673, 677-
682, 686-689 . "The ALJ thus had no opinion from any medical source, treating or
otherwise, as to the significance of the additional records or their implication for
[Plaintiffs] functional abilities ." Russ , 582 F . Supp . 3d at 164.
Additionally, the ALJ had no way to assess the functional limitations existing
after Plaintiffs stent placement surgery. At step two, the ALJ found Plaintiff to have
the severe impairment of"Coronary Artery Disease status post Stent Placement," AR
at 96, meaning that the impairment significantly limited Plaintiffs ability to do basic
work activities . See 20 C.F. R. § 404.1522 (defining non-severe impairments). Yet,
again, none of the opinions were from after the surgery, which occurred in July 2022,
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AR at 686-689, so they could not have considered whether Plaintiff had functional
limitations as a result of the surgery or from his heart disease. Additionally, the stent
was placed in Plaintiffs left circumflex artery, which was 95% blocked, but Plaintiff
also had a 50% blockage in his left anterior descending artery and a 40% blockage in
his "mid LAD." AR at 678. The records do not clarify whether the stent in one artery
improved Plaintiffs functional abilities overall, if additional stents are needed to
address the other blockages, and if Plaintiffs functioning is impaired due to the other
blockages.
The ALJ was not equipped to interpret the cardiology medical records herself,
without input from a medical professional. Cf. Robert W, 2026 WL 2858538 at *4
("the record was sufficient for the ALJ to assess Plaintiffs limitations after his second
hip surgery without a specific medical source opinion"). Here, the ALJ stated that
"during the vast majority of exams, the claimant had normal cardiac impairments
and denied significant cardiac findings." AR at 101. Yet Plaintiff had objectively
significant cardiac findings-his stress test, echocardiogram, 	and abnormal ECG
revealed significantly blocked arteries in his heart that caused chest pain. AR at 673,
680-682. Assuming the ALJ meant that Plaintiff denied chest pain, the medical
records reflect that while Plaintiff denied chest pain at appointments, he reported
that he experienced chest pain while exerting himself. See, 	e.g., AR at 671-672
("Described his chest pain is more related to the activities, such as while walking,
located in the mid chest pressure in nature, 8/10 ... denies current chest pain"). Such
reports were consistent with Plaintiffs testimony, AR at 128-129, and with the
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objective findings during Plaintiffs stress test. AR at 682. Of note, Plaintiff did not
have a repeat stress test after his stent surgery, so the records do not establish that
Plaintiffs exertional limitations reflected during the stress test were alleviated after
surgery. See Russ, 582 F. Supp. 3d at 165 ("The ALJ thus had ample reason to seek
an informed medical opinion of the import of the records rather than improperly
making that determination [her]self."). Without a medical opinion, the Court cannot
find that the ALJ's decision was supported by substantial evidence.
Remand is required to obtain a medical opinion on the effect of Plaintiffs heart
disease and stent placement on his functional capacity.
2. 	On remand, the ALJ can seek clarification regarding the numbers of
jobs that exist in the national economy.
Plaintiff argues that the ALJ erred in finding that significant numbers of jobs
exist that Plaintiff could perform because the VE's numbers were based on the
number of total jobs, and not the number of jobs with the modification of a sit/stand
option. ECF No. 8 at 18-20. The Commissioner responds that the VE testified that
all of the jobs allow for a sit/stand option, so the numbers of jobs that exist in the
national economy are the same with or without that additional limitation. ECF
No.12-1 at 12-14.
At step five, the Commissioner has the burden to establish that work exists in
"significant numbers in the national economy." 20 C.F.R. § 404.1560(c)(l) . "[W]hile it
is true that the Commissioner bears the burden at step five, 'the ALJ, unlike a judge
in a trial, must [her]self affirmatively develop the record in light of the essentially
non-adversarial nature of a benefits proceeding ."' Butts v. Barnhart, 388 F. 3d 377,
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386 (2d Cir. 2004), amended on reh 'g in part , 416 F . 3d 101 (2d Cir. 2005) (quoting
Pratts v. Chater, 94 F . 3d 34, 37 (2d Cir. 1996)).
Here, the ALJ concluded that Plaintiff could perform jobs of assembler and
electronic assembler, and that 35,000 assembler jobs exist nationally and 28,000
electronic motor assembler jobs exist. AR at 103. This finding was consistent with the
VE's testimony about the numbers of those jobs that exist in the national economy.
AR at 143-144.
Yet the VE's testimony is not clear as to whether those numbers should be
reduced, and by how much, with the additional restriction of a sit/stand option. Both
jobs are classified as light, but the VE testified that they allow for postural changes
from sitting to standing. AR at 146-147. The ALJ asked for clarification on the
numbers of jobs that exist in the economy with the sit/stand tolerance: "is that for all
of those jobs that you've listed, or only a portion of them?" AR at 147. The VE
responded, "No, for both of those jobs, the two jobs that we just stated ." AR at 147.
The VE appeared to be speaking about the job classifications, while the ALJ seemed
to be asking about the number of jobs in the economy with the additional restriction.
While the VE's testimony seems to support the Commissioner's interpretation,
because remand is warranted on a separate issue, the ALJ should seek clarification
from the VE regarding the numbers that exist for each job with the sit/stand option.
3. 	The ALJ did not consider the opinion to elevate legs, but the resulting
error was harmless.
Plaintiff argues that his primary care physician Riffat Sadiq, M.D. opined that
he needed to elevate his legs as much as possible, and that the ALJ erred by failing
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to mention that opinion. ECF No. 8 at 20-21. The Commissioner argues that the ALJ
was not required to discuss the opinion because it was contained in a treatment note
rather than in a medical source statement. ECF No. 12-1 at 11. The Corrimissioner
further argues that, in any event, the ALJ adequately discussed Plaintiffs edema and
that his physical examinations did not consistently reveal swelling . ECF No. 12-1 at
11-12.
Regulations effective for all claims filed after March 27, 2017 direct that the
ALJ evaluate the "persuasiveness" of all opinions and prior administrative medical
findings 	in 	the 	record 	by 	assessing 	multiple 	factors, 	including 	supportability,
consistency, the length and nature of the relationship of the source with the claimant,
the source's specialization, and "other factors" that tend to support or contradict a
medical opinion. 20 C.F.R. § 404.1520c(c). While the ALJ need not explain in her
decision how she considered all of the factors, she must explain how she "considered
the supportability and consistency factors for a medical source's medical opinions or
prior administrative medical findings .... "20 C.F.R. § 404.1520c(b)(2).
An ALJ "commit[s] procedural error by failing to explain how it considered the
supportability and consistency of medical opinions in the record ." Loucks v. Kijakazi,
No. 21-1749, 2022 WL 2189293, at *2 (2d Cir. June 17, 2022). The error may be
harmless, however, "if'a searching review of the record assures us that the substance
of the [regulation] was not traversed."' Id. (quoting Estrella v. Berryhill, 925 F. 3d 90,
96 (2d Cir. 2019)).
Here, Plaintiffs primary care physician Dr. Sadiq examined Plaintiff on July
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16, 2021. AR at 535-540. Plaintiff reported an open blister on his left shin not caused
by an injury and dry patches on both feet, and was wearing compression stockings.
AR at 535-536. On examination, he had 1+ edema in both legs and an "open blister
site." AR at 537. Dr. Sadiq assessed Plaintiff with "lymphedema" and advised him to
continue 	using 	compression 	stockings 	and 	"to 	elevate 	BLE 	[bilateral 	lower
extremities] above heart level as much as possible when sitting." AR at 538.
The ALJ did not discuss Dr. Sadiq's recommendation. 	Nevertheless, both
Plaintiffs counsel and Plaintiff discussed elevating his legs during the hearing. AR
at 118-119, 126, 130. The ALJ noted Plaintiffs reported need to elevate his legs, AR
at 98-100, and reasoned that "the exams that noted a normal gait and no significant
swelling or edema did not support a finding of significant ambulatory or postural
limitations, or the need to elevate his legs during the work day." AR at 100. The
treatment records showed both swelling, see, e.g., AR at 469-470, 476, 511, 544, 599,
604, 726, and no swelling, see, e.g., AR at 521, 532, 657, 663, 710, in Plaintiffs legs at
different appointments, so the ALJ's conclusion is supported by substantial evidence.
See Cage v. Comm'r of Soc. Sec., 692 F.3d 118, 122 (2d Cir. 2012) (The Second Circuit
will "defer to the Commissioner's resolution of conflicting evidence.").
While the error would be harmless on its own, because the case is being
remanded 	on 	another 	issue, 	the 	ALJ 	should 	expressly 	consider 	Dr. 	Sadiq's
recommendation on remand.
CONCLUSION
For the foregoing reasons, Plaintiffs motion for judgment on the pleadings,
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ECF No. 8, is GRANTED, and the Commissioner's cross-motion for judgment on the
pleadings, ECF No. 12, is DENIED. The matter is REMANDED under sentence four
of 42 U.S.C. § 405(g) for further administrative proceedings consistent with this
decision.
SO ORDERED.
DATED: 	October _K__, 2026
Rochester, New York
United States District Judge
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