Getman v. Saul

Filing 24

MEMORANDUM-DECISION and ORDER it is ORDERED that the decision of the Commissioner is REVERSED AND REMANDED pursuant to sentence four of 42 U.S.C. § 405(g) for proceedings consistent with this Memorandum-Decision & Order; and it is further ORDERE D that the Clerk amend the caption to substitute KILOLO KIJAKAZI, Acting Commissioner of Social Security, for Defendant ANDREW M. SAUL, the former Commissioner of Social Security; and it is further ORDERED that the Clerk provide a copy of this Memorandum-Decision and Order to the parties in accordance with the Local Rules of the Northern District of New York. IT IS SO ORDERED. Signed by Senior Judge Norman A. Mordue on May 9, 2022. (gmd, )

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UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF NEW YORK
_______________________________________
MELANIE G.
Plaintiff,
v.

5:20-CV-01630 (NAM)

KILOLO KIJAKAZI,
Acting Commissioner of Social Security,
Defendant.
_______________________________________
APPEARANCES:
Justin Goldstein
Kenneth Hiller
Law Offices of Kenneth Hiller
6000 North Bailey Avenue, Suite 1A
Amherst, NY 14226
Attorney for Plaintiff
Hugh Dun Rappaport
Social Security Administration
J.F.K. Federal Building, Room 625
15 New Sudbury Street
Boston, MA 02203
Attorney for Defendant
Hon. Norman A. Mordue, Senior United States District Court Judge:
MEMORANDUM-DECISION AND ORDER
I.

INTRODUCTION
Plaintiff Melanie G. filed this action on December 31, 2020 under 42 U.S.C. § 405(g),

challenging the denial of her application for Supplemental Security Income (“SSI”) benefits
under the Social Security Act. (Dkt. No. 1). After carefully reviewing the Administrative

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Record, (“R,” Dkt. No. 12), the Court reverses the decision of the Commissioner and remands
for further proceedings.
II.

BACKGROUND
On April 4, 2019, Plaintiff filed an application for SSI benefits, alleging that she became

disabled on January 29, 2018 due to the following conditions: 1) agoraphobia with panic
disorder; 2) anxiety disorder; 3) posttraumatic stress disorder (“PTSD”); 4) major depressive
disorder (“MDD”); 5) asthma disorder; 6) migraine disorder; and 7) obesity. (R. 64–65, 193,
226, 244–51).
Plaintiff’s claim was initially denied on June 10, 2019, and again on reconsideration on
October 28, 2019. (R. 117, 125). Plaintiff requested a hearing, and on April 1, 2020, she
appeared and testified at a telephone hearing before Administrative Law Judge (“ALJ”) Kenneth
Theurer. (R. 33–63, 137). On April 4, 2020, ALJ Theurer issued a written decision denying
Plaintiff’s claim. (R. 16–32). The Appeals Council denied review, (R. 1–6), and Plaintiff then
commenced this action, (Dkt. No. 1).
Plaintiff’s Background and Testimony
Plaintiff was born in 1983 and was 32 years old as of the alleged onset date of disability.
(R. 213). She has a ninth-grade education with special education services. (R. 226). She
previously worked as a cashier and daycare provider. (R. 203–12, 217–24, 227, 233–41).
At the hearing, Plaintiff testified that she cannot work due to anxiety, panic attacks,
depression, and agoraphobia. (R. 48, 53). Plaintiff testified that she also has PTSD. (R. 48).
Plaintiff said that she takes medication and receives counseling, but still has good days and bad
days. (R. 50). Plaintiff testified that she spends most of her time at home taking care of her twoyear old child. (R. 50). She does not drive, but she is able to cook and clean. (R. 51).

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Medical Evidence
1.

Treatment Records

On October 7, 2013, Plaintiff was admitted to treatment at Liberty Resources Brownell
Center for Behavioral Health (“Liberty”). (R. 282). As of November 4, 2013, she had
symptoms of MDD, including lethargy, lack of interest, isolation from others, and tearfulness.
(R. 282). She also had panic attacks and social anxiety, and PTSD symptoms including
flashbacks, nightmares, and triggering. (R. 282). She had symptoms of anxiety including heart
racing, nervousness, and excessive worry. (R. 282). Her symptoms were causing interference in
activities of daily living. (R. 282). As of November 3, 2015, she was diagnosed with
agoraphobia with panic disorder, PTSD, and MDD. (R. 283).
On June 11, 2018, Plaintiff was seen at Liberty and received a treatment plan, which was
updated with progress notes several times in 2018 and 2019. (R. 290–98, 714–54, 776–99). On
January 16, 2019, Plaintiff saw Nurse Practitioner (“NP”) Heather Henderson. (R. 709–13).
Plaintiff reported her mood as fair, with increased anxiety and depression. (R. 709). NP
Henderson examined Plaintiff and noted among other things: “thought process coherent, linear,
and goal-directed”; no evidence of psychosis; fair affect range; fair recent and remote memory;
fair concentration; fair attention; fair abstraction; fair insight; fair judgment; and fair impulsivity.
(R. 710). NP Henderson assessed Plaintiff with chronic depression and moderate to severe
panic/anxiety. (R. 711). She prescribed medication to treat anxiety and depression and advised
Plaintiff to continue psychotherapy. (R. 712).
On March 1, 2019, NP Henderson treated Plaintiff for panic disorder with agoraphobia
and MDD. (R. 702–06). Plaintiff reported her mood as fair, and that her conditions were
responding to medication. (R. 703–04). On examination, NP Henderson noted: “thought

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process coherent, linear, and goal-directed”; no evidence of psychosis; fair affect; fair recent and
remote memory; fair attention; fair abstraction; fair insight; fair judgment; and fair impulsivity.
(R. 703). NP Henderson again assessed Plaintiff with chronic depression and moderate to severe
panic/anxiety. (R. 703). Plaintiff was continued on medication and psychotherapy. (R. 703).
On April 26, 2019, NP Henderson treated Plaintiff for panic disorder with agoraphobia
and MDD. (R. 695–99). Plaintiff reported her mood as fair, and that her conditions were
responding to medication. (R. 696–97). On examination, NP Henderson noted: “thought
process coherent, linear, and goal-directed”; no evidence of psychosis; fair mood; fair affect; fair
recent and remote memory; fair attention; fair abstraction; fair insight; fair judgment; and fair
impulsivity. (R. 696). NP Henderson again assessed Plaintiff with chronic depression and
moderate to severe panic/anxiety and continued her on medication and psychotherapy. (R. 696).
On June 14, 2019, NP Henderson treated Plaintiff for panic disorder with agoraphobia
and MDD. (R. 300–04). Plaintiff reported that her mood was generally good, and that her
anxiety level had been manageable recently. (R. 301–02). On examination, NP Henderson
noted: “thought process coherent, linear, and goal-directed”; no evidence of psychosis; fair
affect; fair recent and remote memory; fair attention; fair abstraction; fair insight; fair judgment;
and fair impulsivity. (R. 301). NP Henderson assessed chronic depression and chronic
panic/anxiety. (R. 302).
On August 29, 2019, Plaintiff returned to Liberty to update her treatment plan. (R. 282–
89, 800–08). Plaintiff reported struggling to manage her symptoms of depression, such as
isolating, low energy/fatigue, difficulties sleeping, tearfulness, depressed mood, and low selfesteem due to her diagnosis of PTSD. (R. 284). She also had panic disorder symptoms and

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struggled with anxiety and hypervigilance as it related to PTSD. (R. 285). She was treating
with therapists Rebecca Preston and Agnieszka Hope Williams every other week. (R. 284–88).
The following day, August 30, 2019, NP Henderson treated Plaintiff for panic disorder
and MDD. (R. 310–11, 313–18). Plaintiff reported that her mood was generally good, and that
her symptoms were responding to medication. (R. 313). On examination of Plaintiff, NP
Henderson noted: “thought process coherent, linear, and goal-directed”; no evidence of
psychosis; fair affect; fair recent and remote memory; fair attention; fair abstraction; fair insight;
fair judgment; and fair impulsivity. (R. 314). Plaintiff was continued on medication and
psychotherapy. (R. 313).
On October 25, 2019, Plaintiff saw NP Henderson again and reported that her anxiety
level was high. (R. 828–33). NP Henderson’s examination findings remained largely the same.
(R. 831). Plaintiff was continued on medication and psychotherapy. (R. 830). On December
20, 2019, Plaintiff saw NP Henderson and reported that her mood was generally good and her
anxiety was responding well to medication. (R. 834–39). NP Henderson’s examination findings
remained largely the same. (R. 836). NP Henderson assessed chronic depression and chronic
panic/anxiety, and continued Plaintiff on medication and psychotherapy. (R. 836–37).
2.

Opinion Evidence

On May 28, 2019, State agency consultant Dante Alexander, Psy.D. completed an adult
psychiatric evaluation for Plaintiff. (R. 756–60). Plaintiff reported receiving outpatient mental
health treatment with Heather Henderson; she was prescribed Pristiq and Buspirone; she avoided
social settings; she had panic attacks consisting of palpations and sweating; and she had wordfinding deficits, difficulty learning new material, organizational difficulties, and planning
difficulties. (R. 756). On examination, Plaintiff’s attention and concentration were found mildly

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impaired due to limited math ability; her memory was intact; her intellectual functioning was
estimated at borderline; and her general fund of information was somewhat limited. (R. 757).
Dr. Alexander found no evidence of limitations for understanding, remembering, or applying
simple or complex directions and instructions. (R. 758). But Dr. Alexander assessed the
following limitations:
Mild limitation using reasoning and judgment to make work-related
decisions. Mild to moderate limitation interacting adequately with
supervisors, coworkers, and the public. Mild limitations sustaining
concentration and performing at a task at a consistent pace. Mild
limitation sustaining an ordinary routine or regular attendance at
work. Mild to moderate limitation regulating emotion, controlling
behavior, and maintaining well-being.
(R. 758). Dr. Alexander noted that Plaintiff’s difficulties were caused by distractibility. (R.
758). Dr. Alexander diagnosed Plaintiff with social anxiety disorder with anxiety attacks, with a
fair prognosis. (R. 758).
On June 3, 2019, non-examining State agency medical consultant, M. VasquezGonzalez, M.D., assessed that, due to her asthma, Plaintiff should avoid concentrated exposures
to fumes, odors, dusts, gases, poor ventilation, etc. (R. 70–72). On June 4, 2019, nonexamining State agency psychological consultant, C. Walker, Ph.D. assessed that, due to her
anxiety and depression, Plaintiff had: moderate limitations interacting with others; moderate
limitations concentrating, persisting, or maintaining pace; and adapting or managing oneself. (R.
68–69). This opinion was affirmed by S. Hennessey, Ph.D. on October 1, 2019. (R. 773–75).
On March 16, 2020, NP Henderson completed a medical source statement. (R. 945–47).
NP Henderson noted that she treated Plaintiff every two months or as needed for medication
management, and that Plaintiff saw a therapist bi-weekly. (R. 945). NP Henderson listed
Plaintiff’s diagnoses as MDD, Panic Disorder, asthma, hypertension, and sleep apnea, with a

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guarded prognosis. (R. 945). NP Henderson identified supporting signs and symptoms as:
anhedonia or pervasive loss of interest in almost all activities; appetite disturbance with weight
change; decreased energy; feelings of guilt or worthlessness; generalized persistent anxiety;
mood disturbance; difficulty thinking or concentrating; recurrent and intrusive recollections of a
traumatic experience, which are a source of marked distress; easy distractibility; sleep
disturbance; emotional withdrawal or isolation; and recurrent severe panic attacks manifested by
a sudden, unpredictable onset of intense apprehension, fear, terror, and sense of impending doom
occurring on the average of at least once per week. (R. 945–46).
As to mental abilities and aptitudes needed to do unskilled work, NP Henderson found
that Plaintiff was unable to meet competitive standards in her abilities to: 1) complete a normal
workday or workweek without interruptions from psychologically based symptoms; 2) accept
instructions and respond appropriately to criticism from supervisors; 3) respond appropriately to
changes in a routine work setting; and 4) deal with normal work stress. (R. 946). She was
seriously limited in her abilities to ask simple questions or request assistance. (R. 946). NP
Henderson noted that Plaintiff had left jobs in the past due to panic attacks and anxiety; she had
reported and demonstrated anxiety and distractibility when interacting with others; and changes
and unfamiliar places and people also triggered her anxiety. (R. 946). NP Henderson found that
Plaintiff was unable to meet competitive standards as to traveling in unfamiliar place and using
public transportation, noting that she experienced panic attacks in unfamiliar situations. (R.
947). Plaintiff also experienced migraines which could be triggered by her anxiety. (R. 947).
NP Henderson assessed that Plaintiff would be absent from work on average more than four
days per month due her impairments or treatment. (R. 947).
ALJ’s Decision Denying Benefits

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At step one of the five-step evaluation process, the ALJ determined that Plaintiff had not
engaged in substantial gainful employment since April 4, 2019, her application date. (R. 21). At
step two, the ALJ determined that Plaintiff had the following “severe” impairments: 1) asthma;
and 2) anxiety and depression. (R. 21) (citing 20 C.F.R. § 416.920(c)).
At step three, the ALJ found that Plaintiff “does not have an impairment or combination
of impairments that meets or medically equals the severity of one of the listed impairments in 20
C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 404.1525 and 404.1526,
416.920(d), 416.925 and 416.926).” (R. 22).
At step four, the ALJ determined that Plaintiff had the residual functional capacity
(“RFC”) to perform a full range of work at all exertional levels with the following nonexertional limitations:
[T]he claimant should avoid concentrated exposure to smoke, dust, and
respiratory irritants. She retains the ability to understand and follow simple
instructions and directions; perform simple tasks with supervision and
independently; maintain attention/concentration for simple tasks; regularly
attend to a routine and maintain a schedule; she can relate to and interact
with coworkers and supervisors to the extent necessary to carry out simple
tasks-i.e. she can ask for help when needed: handle conflicts with others:
state her own point of view: initiate or sustain a conversation, and
understand and respond to physical, verbal and emotional social cues but
she should avoid work requiring more complex interaction or joint efforts
with coworkers to achieve work goals. The claimant should have no more
than occasional contact with coworkers and supervisors and should have no
more than incidental contact with the public. The claimant can handle
reasonable levels of simple work-related stress in that she can make simple
decisions directly related to the completion of her tasks in a stable,
unchanging work environment.
(R. 24).
Next, the ALJ found that Plaintiff had no past relevant work. (R. 27). The ALJ noted
that Plaintiff was 35 years old when she applied for SSI benefits, she had a limited education,
and she was able to communicate in English. (R. 27). The ALJ then asked a vocational expert
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whether “jobs exist in the national economy for an individual with the claimant’s age,
education, work experience, and residual functional capacity.” (R. 27). The vocational expert
responded that such jobs included packager, dining room attendant, marker II, and router. (R.
28). Based on this testimony, the ALJ concluded that considering Plaintiff’s age, education,
work experience, and RFC, she was “capable of making a successful adjustment to other work
that exists in significant numbers in the national economy.” (R. 28). Consequently, the ALJ
found that Plaintiff was not disabled. (R. 28).
III.

STANDARD OF REVIEW
A.

Disability Standard

To be considered disabled, a claimant must establish that 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 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, the claimant’s impairment(s) must be “of such severity that she is not only unable to do
her previous work but cannot, considering her age, education, and work experience, engage in
any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. §
1382c(a)(3)(B).
The Social Security Administration uses a five-step process to evaluate disability claims:
First, the Commissioner considers whether the claimant is currently
engaged in substantial gainful activity. If she is not, the
Commissioner next considers whether the claimant has a “severe
impairment” which significantly limits 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 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 her [per se] disabled . . . . Assuming the claimant does not
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have a listed impairment, the fourth inquiry is whether, despite the
claimant’s severe impairment, she has the residual functional
capacity to perform her past work. Finally, if the claimant is unable
to perform her past work, the Commissioner then determines
whether there is other work which the claimant can perform.
Selian v. Astrue, 708 F.3d 409, 417–18 (2d Cir. 2013) (quoting Talavera v. Astrue, 697 F.3d
145, 151 (2d Cir. 2012)); see also 20 C.F.R. §§ 404.1520, 416.920. The claimant bears the
initial burden of establishing disability at the first four steps; the Commissioner bears the burden
at the last. Selian, 708 F.3d at 418.
B.

Standard of Review

In reviewing a final decision by the Commissioner under 42 U.S.C. § 405, the Court does
not determine de novo whether Plaintiff is disabled. Rather, the Court must review the
administrative record to determine whether “there is substantial evidence, considering the record
as a whole, to support the Commissioner’s decision and if the correct legal standards have been
applied.” Moran v. Astrue, 569 F.3d 108, 112 (2d Cir. 2009) (citation omitted).
When evaluating the Commissioner’s decision, “the reviewing court is required to
examine the entire record, including contradictory evidence and evidence from which conflicting
inferences can be drawn.” Selian, 708 F.3d at 417 (citation omitted). The Court may set aside
the final decision of the Commissioner only if it is not supported by substantial evidence or if it
is affected by legal error. 42 U.S.C. § 405(g); Selian, 708 F.3d at 417; Talavera, 697 F.3d at
151. “Substantial evidence is more than a mere scintilla. It means such relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.” Brault v. Soc. Sec. Admin.,
Comm’r, 683 F.3d 443, 447–48 (2d Cir. 2012) (quoting Moran, 569 F.3d at 112).
C.

Evaluating Medical Opinions

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For claims filed after March 27, 2017, as is the case here, the Commissioner must
consider all medical opinions and “evaluate their persuasiveness” based on the following five
factors: supportability; consistency; relationship with the claimant; specialization; and “other
factors.” 20 C.F.R. §§ 404.1520c(a)–(c), 416.920c(a)–(c). The ALJ is still required to
“articulate how he considered the medical opinions” and “how persuasive he finds all of the
medical opinions.” Id. at §§ 404.1520c(a) and (b)(1), 416.920c(a) and (b)(1). The two “most
important factors for determining the persuasiveness of medical opinions are consistency and
supportability,” and an ALJ is required to “explain how he considered the supportability and
consistency factors” for a medical opinion. Id. at §§ 404.1520c(b)(2), 416.920c(b)(2).
With respect to “supportability,” the Regulations provide that “[t]he 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. at §§
404.1520c(c)(1), 416.920c(c)(1). The Regulations provide that with respect to “consistency,”
“[t]he more consistent a medical opinion(s) or prior administrative medical finding(s) is with
the evidence from other medical sources and nonmedical sources in the claim, the more
persuasive the medical opinion(s) or prior administrative medical finding(s) will be.” Id. at §§
404.1520c(c)(2), 416.920c(c)(2).
IV.

DISCUSSION
Plaintiff challenges the ALJ’s decision to deny her SSI benefits on the grounds that the

ALJ erred in his analysis of the medical opinions and failed to identify substantial evidence to
support Plaintiff’s RFC. (Dkt. No. 17, p. 9). In response, the Commissioner counters that the
ALJ properly evaluated the evidence when formulating the RFC. (Dkt. No. 22, p. 3).

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Medical Opinions
First, Plaintiff objects to the ALJ’s analysis of the opinions given by NP Henderson and
Drs. Alexander, Walker, and Hennessey. (Dkt. No. 17, pp. 11–20).
1. NP Henderson
On March 16, 2020, NP Henderson completed a medical source statement for Plaintiff.
(R. 945–47). As relevant here, NP Henderson diagnosed Plaintiff with MDD with Panic
Disorder. (R. 945). NP Henderson assessed that due to Plaintiff’s mental impairments, she was
unable to meet competitive standards for: completing a normal workday and workweek without
interruptions from psychologically based symptoms; accepting instructions and responding
appropriately to criticism from supervisors; responding appropriately to changes in a routine
work setting; and dealing with normal work stress. (R. 946). NP Henderson further opined that
Plaintiff was seriously limited in her ability to ask simple questions or request assistance. (R.
946). NP Henderson also opined that Plaintiff was limited in her abilities to: maintain regular
attendance and work with others without being unduly distracted or exhibiting behavioral
extremes. (R. 946). NP Henderson opined that Plaintiff was unable to travel to unfamiliar
places or use public transportation due to her reported panic attacks. (R. 947). NP Henderson
assessed that Plaintiff would be absent from work on average more than four days per month due
to her impairments or treatment. (R. 947).
The ALJ found that NP Henderson’s opinion was not persuasive because it was “not
consistent with the record as a whole including the [plaintiff’s] normal mental health symptom
evaluations as reported in the record, and it is not consistent with the other medical opinions in
the record.” (R. 26). The ALJ also stated that “NP Henderson’s assessments are not tied to

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clinical findings such as the conclusion that the claimant will miss more than four days per
month.” (R. 26).
Plaintiff contends that the ALJ mischaracterized her mental health evaluations as normal
and failed to discuss numerous abnormal findings. (Dkt. No. 17, pp. 12–13). The Court agrees.
While the ALJ noted a few normal findings, the record shows that Plaintiff consistently reported
symptoms of anxiety and depression, and her primary mental health medical provider, NP
Henderson, consistently documented below normal clinical findings. For example, on January
16, 2019, Plaintiff saw NP Henderson and reported increased anxiety and depression. (R. 709).
On examination, NP Henderson noted that Plaintiff had a coherent thought process and no
evidence of psychosis, but NP Henderson also found that Plaintiff had only fair affect range,
recent and remote memory, concentration, attention, abstraction, insight, judgment, and
impulsivity. (R. 710). NP assessed that Plaintiff had chronic depression and moderate to severe
chronic panic/anxiety, and she prescribed medication to treat both conditions. (R. 711–12).
Although Plaintiff sometimes showed improvement, her symptoms and NP Henderson’s
assessments were much the same on six other visits that year. (R. 301, 314, 696, 703, 830, 836).
Therefore, it was not accurate for the ALJ to summarize Plaintiff’s mental health symptom
evaluations as normal, which compromised the ALJ’s analysis as to the consistency of NP
Henderson’s opinion with the overall record. 1
Further, Plaintiff argues that the ALJ did not identify “any legitimate inconsistency”
between the opinion of NP Henderson and those of the other medical sources. (Dkt. No. 17, pp.
14–15). However, the ALJ cited several findings in the opinions of Drs. Alexander, Walker, and

The ALJ’s analysis also fails to recognize that mental health conditions often do not progress in a linear
fashion, but rather “[c]ycles of improvement and debilitating symptoms [of mental illness] are a common
occurrence.” Estrella v. Berryhill, 925 F.3d 90, 97 (2d Cir. 2019).
1

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Hennessey that differed from NP Henderson’s assessment, as pointed out by the Commissioner.
For example, the ALJ noted that Dr. Alexander found no evidence that Plaintiff had a limitation
for understanding, remembering, or applying simple directions and instructions, (R. 26), whereas
NP Henderson found that Plaintiff was unable to meet competitive standards for accepting
instructions, (R. 946). The ALJ also noted that Drs. Walker and Hennessey found that Plaintiff
was able to maintain adequate attention to complete work tasks on an ongoing basis, (R. 26),
whereas NP Henderson found that Plaintiff’s ability to concentrate was only fair and that she
was unable to meet competitive standards for completing a workday without interruption from
psychologically based symptoms, (R. 946). The Commissioner also points out several other
notable inconsistencies. (Dkt. No. 22, pp. 5–6). Therefore, the ALJ did not err in concluding
that NP Henderson’s opinion was inconsistent with the other medical opinions.
Third, Plaintiff claims that the ALJ failed to “identify any evidence inconsistent with or
unsupportive of NP Henderson’s assessment of absence-related limitations.” (Dkt. No. 17, p.
16). Relatedly, Plaintiff contends that the ALJ did not apply the supportability factor regarding
NP Henderson’s opinion. (Id., pp. 17–18). As discussed above, when analyzing a medical
opinion, an ALJ is required to “explain how [he] considered the supportability and consistency
factors.” 20 C.F.R. §§ 404.1520c(b)(2), 416.920c(b)(2). Here, the ALJ appeared to address
supportability when he concluded that the NP Henderson’s assessments were “not tied to clinical
findings.” (R. 26). However, the ALJ’s analysis is once again inaccurate. NP Henderson
assessed that Plaintiff would miss than four days of work per month due to her Major
Depression and Panic Disorders. (R. 945). In support of this opinion, NP Henderson cited
Plaintiff’s signs and symptoms including: generalized persistent anxiety, mood disturbance,
difficulty thinking or concentrating, emotional withdrawal or isolation, and easy distractibility.

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(R. 945). NP Henderson also noted that Plaintiff “demonstrated anxiety and distractibility when
interacting with others.” (R. 946). Further, the ALJ failed to note that NP Henderson’s opinion
was largely consistent with and supported by her mental status evaluations of Plaintiff, as
discussed above. For example, NP Henderson’s finding that Plaintiff had moderate to severe
panic/anxiety tends to support an absence-related restriction. (See R. 711). Accordingly, the
Court concludes that the ALJ’s analysis of NP Henderson’s opinion is not supported by
substantial evidence for this reason as well. 2
2. Drs. Alexander, Walker, and Hennessey
Dr. Alexander, the consultative examiner, and Drs. Walker and Hennessey, the nonexamining consultants, generally opined that Plaintiff had mild or no limitations for her mental
functioning. (R. 68–69, 84, 758, 773–75). The ALJ found Dr. Alexander’s opinion to be
“persuasive due to the Doctor’s program knowledge, the opinion being supported by the findings
from the Doctor’s examination of the claimant and the opinion being consistent with objective
evidence in the overall longitudinal record.” (R. 26). Similarly, the ALJ found that the opinions
of Drs. Walker and Hennessey were also persuasive “due to the Doctors’ program knowledge,
the opinions being supported with explanations and consistent with objective evidence in the
overall longitudinal record.” (R. 26).
However, Plaintiff argues that “[t]he ALJ’s citation to the ‘overall longitudinal record’ is
insufficient to identify the evidence consistent with the opinions.” (Dkt. No. 17, p. 19). In
response, the Commissioner contends that “the same evidence . . . that supports the ALJ’s
decision to discount Ms. Henderson’s opinion” also supports the ALJ’s decision to find the other
To the extent the ALJ did not consider NP Henderson’s mental status evaluations as “clinical findings,”
it is not clear what would have sufficed. In the context of mental health conditions, where objective tests
are elusive, a medical provider can often only be expected to review the patient’s history based on her
subjective symptoms, conduct a mental status examination, and assess the patient’s ability to function.
2

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medical opinions more persuasive. (Dkt. No. 22, p. 18). But as discussed above, the ALJ
mischaracterized the “overall longitudinal record” in this case by largely omitting the abnormal
mental health findings from NP Henderson’s evaluations of Plaintiff. Thus, the ALJ’s analysis
is flawed as to the opinions of Drs. Alexander, Walker, and Hennessey, and the Court cannot say
that substantial evidence supports the ALJ’s heavy reliance on these opinions.
Residual Functional Capacity
Finally, Plaintiff argues that the ALJ’s assessments of her social limitations and stressrelated limitations are not supported by substantial evidence. (Dkt. No. 17, pp. 20–24). The
Commissioner counters that the ALJ permissibly discounted NP Henderson’s opinion and cited
substantial evidence for the RFC in the “more persuasive” opinions of Drs. Alexander, Walker,
and Hennessy. (Dkt. No. 22, pp. 11–23).
As discussed above, the ALJ erred in evaluating the opinion of NP Henderson (and her
longitudinal treatment records), which in turn undermined the ALJ’s analysis of the opinions of
Drs. Alexander, Walker, and Hennessey. Under these circumstances, the latter opinions do not
on their own amount to substantial evidence for the RFC. Accordingly, the Court declines to
address the parties’ additional argument as to the RFC since remand is necessary for the ALJ to
reconsider the medical opinions and Plaintiff’s overall RFC. See Brenda E. v. Saul, No. 20-CV093, 2021 WL 66545, at *7, 2021 U.S. Dist. LEXIS 2640, at *19 (N.D.N.Y. Jan. 7, 2021)
(“Because this matter requires remand for the ALJ to reevaluate [the doctor’s] medical opinion
and plaintiff’s RFC, the court need not address plaintiff’s remaining arguments on the merits.”);
Andrew G. v. Commr. of Soc. Sec., No. 19-CV-942, 2020 WL 5848776, at *6–9; 2020 U.S. Dist.
LEXIS 182212, at *18–27 (N.D.N.Y. Oct. 1, 2020) (remanding due to the ALJ’s failure to
adequately explain the supportability or consistency factors that led to her decision).

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Case 5:20-cv-01630-NAM Document 24 Filed 05/09/22 Page 17 of 17

V.

CONCLUSION
For these reasons, it is
ORDERED that the decision of the Commissioner is REVERSED AND REMANDED

pursuant to sentence four of 42 U.S.C. § 405(g) for proceedings consistent with this
Memorandum-Decision & Order; and it is further
ORDERED that the Clerk amend the caption to substitute KILOLO KIJAKAZI,
Acting Commissioner of Social Security, for Defendant ANDREW M. SAUL, the former
Commissioner of Social Security; and it is further
ORDERED that the Clerk provide a copy of this Memorandum-Decision and Order to
the parties in accordance with the Local Rules of the Northern District of New York.
IT IS SO ORDERED.
Date: May 9, 2022
Syracuse, New York

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