Carl v. Commissioner of Social Security
DECISION AND ORDER Plaintiff's motion for judgment on the pleadings 14 is granted, and the Commissioner's cross-motion 15 is denied. The Commissioner's decision that plaintiff was not disabled is reversed, and the matter is remande d for further proceedings, for the narrow purpose of gathering and considering additional evidence and medical opinions with respect to plaintiff's cardiac impairments and alleged visual impairment.Upon remand, the Commissioner is instructed to request missing treatment records and complete RFC reports from plaintiff's treating source(s), and/or to order consultative examinations or medical expert testimony, sufficient to permit the reconsideration of plaintiff's claim in its e ntirety. Such reconsideration should include reassessment of the severity of plaintiff's alleged visual impairment, and of the limitations imposed by plaintiff's cardiac impairments and visual impairment, if any, upon her ability to perform work-related functions. Signed by Hon. David G. Larimer on 5/9/2022. (KAH)-CLERK TO FOLLOW UP-
Case 1:20-cv-01882-DGL Document 19 Filed 05/09/22 Page 1 of 6
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
DECISION AND ORDER
Acting Commissioner of Social Security,
Plaintiff appeals from a denial of disability benefits by the Commissioner of Social Security
(“the Commissioner”). The action is one brought pursuant to 42 U.S.C. § 405(g) to review the
Commissioner’s final determination.
On September 2, 2016, plaintiff, then fifty-three years old, filed applications for a period
of disability and disability insurance benefits, as well as supplemental security income benefits,
alleging an inability to work since July 27, 2016. Her application was initially denied. Plaintiff
requested a hearing, which was held on March 21, 2019 via videoconference before Administrative
Law Judge (“ALJ”) Stephen Cordovani. (Administrative Transcript, Dkt. #9 at 96). The ALJ
issued a decision on July 7, 2018, concluding that plaintiff was not disabled under the Social
Security Act. (Dkt. #9 at 96-108). That decision became the final decision of the Commissioner
when the Appeals Council denied review on October 29, 2020. (Dkt. #9 at 1-3). Plaintiff now
The plaintiff has moved for judgment remanding the matter for further proceedings (Dkt.
#14), and the Commissioner has cross moved for judgment on the pleadings (Dkt. #15), pursuant
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to Fed. R. Civ. Proc. 12(c). For the reasons set forth below, the plaintiff’s motion is granted, the
Commissioner’s cross motion is denied, and the matter is remanded for further proceedings, in the
manner and to the extent described below.
Determination of whether a claimant is disabled within the meaning of the Social Security
Act requires a five-step sequential evaluation, familiarity with which is presumed. See Bowen v.
City of New York, 476 U.S. 467, 470-71 (1986). The Commissioner’s decision that a plaintiff is
not disabled must be affirmed if it is supported by substantial evidence, and if the ALJ applied the
correct legal standards. See 42 U.S.C. § 405(g); Machadio v. Apfel, 276 F.3d 103, 108 (2d Cir.
The ALJ’s Decision
Here, the ALJ found that the plaintiff has the following severe impairments, not meeting
or equaling a listed impairment: coronary artery disease, chronic systolic congestive heart failure,
ischemic cardiomyopathy (weakening of the heart muscle, compromising the ability to pump blood
properly), and a history of cardiac arrest. (Dkt. #9 at 99).
The ALJ also considered plaintiff’s diagnoses of Type II diabetes, hypertension, high
thyroid stimulating hormone (“TSH”) levels, gout, degenerative disc disease, and blurred vision,
and determined that none of these arose to the level of a severe impairment. (Dkt. #9 at 99-100).
The record also contained treatment records for depression and anxiety. Applying the
special technique to plaintiff’s mental impairments, the ALJ found that plaintiff has a mild
limitation in understanding, remembering and applying information; a mild limitation in
interaction with others; a mild limitation in concentration, persistence and pace; and a mild
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limitation in adapting and managing herself. (Dkt. #9 at 100-101). He accordingly found plaintiff’s
mental health impairments to be non-severe.
After summarizing the evidence of record, the ALJ determined that plaintiff retains the
residual functional capacity (“RFC”) to perform sedentary work, with limitations to no more than
occasional climbing of ramps and stairs, balancing, kneeling, crouching, and crawling. Plaintiff
can never climb ladders, ropes, or scaffolds, and must avoid working around hazards such as
unprotected heights, moving mechanical parts, or flammable liquids. Finally, she must avoid
concentrated exposure to respiratory irritants including fumes, odors, dusts, and gases. (Dkt. #9 at
When asked at the hearing whether there were jobs in the economy that a person with this
RFC could perform, vocational expert Timothy P. Janikowski testified that such an individual
could perform plaintiff’s past relevant work as an inspector of semiconductor wafers. (Dkt. #9 at
The ALJ accordingly found plaintiff not disabled. This appeal followed.
Plaintiff’s Severe Cardiac Impairments
The ALJ’s decision made detailed findings with respect to plaintiff’s RFC, citing plaintiff’s
medical records, examination findings, and the opinions of treating, consulting and reviewing
However, I concur with plaintiff that the record is incomplete with respect to the effect of
plaintiff’s several cardiac impairments on her exertional capacity, and as such, the matter must be
remanded for the purpose of obtaining additional medical opinion evidence specific to that issue.
“Because a hearing on disability benefits is a non-adversarial proceeding, the ALJ
generally has an affirmative obligation to develop the administrative record.” Perez v. Chater, 77
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F.3d 41, 47 (2d Cir. 1996). The record in this case contained treatment records and objective testing
which established a number of cardiac deficiencies, and the ALJ accordingly determined that
plaintiff’s coronary artery disease, chronic systolic congestive heart failure, ischemic
cardiomyopathy, and history of cardiac arrest, were severe impairments. (Dkt. #9 at 99.) However,
the record lacked any medical opinion evidence or objective assessment of the effect of those
impairments upon plaintiff’s ability to perform exertional tasks. Indeed, the only examining
physician to address plaintiff’s cardiac impairments, consulting internist Dr. Nikita Dave (Dkt. #9
at 508-513), explicitly stated that she was “unable to comment” on the specific limitations that
plaintiff’s heart problems might impose, and instead opined that plaintiff “should remain under
strict cardiac restrictions [imposed by plaintiff’s] surgeon or cardiologist.” (Dkt. #9 at 512).
Unfortunately, plaintiff’s treating cardiologist declined to provide a medical opinion.
Plaintiff’s cardiac impairments were the only ones the ALJ found to be severe. The absence
of any medical opinion or other comprehensive assessment of the effect of those impairments on
plaintiff’s RFC created a clear evidentiary gap, and resulted in an RFC finding that was based
solely upon the ALJ’s layperson interpretation of “raw data” in the record, such as objective
measurements of extremity strength, blood pressure measurements, and stress test results. See
Cruver v. Commissioner, 2020 U.S. Dist. LEXIS 137683 at *4-*5 (W.D.N.Y. 2020) (remand is
required where the ALJ “did not rely on any medical opinions” in reaching his highly-specific
exertional findings); Bailey v. Commissioner, 2020 U.S. Dist. LEXIS 128280 at *19 (W.D.N.Y.
2020) (an ALJ’s use of lay judgment to formulate an RFC is reversible error, and requires remand
“so that the ALJ can develop the medical record and ground the physical RFC determination in a
medical opinion or opinions in the record”).
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In light of this gap, the ALJ should have attempted to obtain RFC reports from treating
sources which specifically assessed plaintiff’s limitations relating to her cardiac impairments, and
failing that, should have obtained a reliable and “conclusive determination from a medical
consultant” who was able to review the record with respect to that issue and perform an in-person
evaluation. Falcon v. Apfel, 88 F. Supp. 2d 87, 90 (W.D.N.Y. 2000). See generally 20 C.F.R.
§404.1519a(b)(4)(an ALJ must order a consultative examination when a “conflict, inconsistency,
ambiguity or insufficiency in the evidence must be resolved”).
Plaintiff also alleges that the ALJ erred in failing to obtain more complete records from the
office of her optometrist, which despite a ten-year treatment history, produced just one treatment
record and one inscrutable RFC opinion which is almost entirely blank, consists entirely of two
circled words without elaboration, and identifies no particular diagnoses or impairments. (Dkt. #9
at 625-30). Plaintiff contends that due to this evidentiary gap, the ALJ’s finding that plaintiff’s
blurry vision was non-severe was not supported by substantial evidence.
The Court concurs. Because the record before the ALJ was insufficient for him to make a
well-supported determination concerning the severity and extent of plaintiff’s visual limitations (if
any), further development of the record with respect to plaintiff’s eyesight is also necessary and
appropriate. See Falcon, 88 F. Supp. 2d 87 at 90; Bailey, 2020 U.S. Dist. LEXIS 128280 at *19.
Plaintiff’s Other Arguments
The Court has considered the remainder of plaintiff’s arguments and objections to the
ALJ’s decision and to the completeness of the record, and finds them to be without merit.
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For the foregoing reasons, plaintiff’s motion for judgment on the pleadings (Dkt. #14) is
granted, and the Commissioner’s cross-motion (Dkt. #15) is denied. The Commissioner’s decision
that plaintiff was not disabled is reversed, and the matter is remanded for further proceedings, for
the narrow purpose of gathering and considering additional evidence and medical opinions with
respect to plaintiff’s cardiac impairments and alleged visual impairment.
Upon remand, the Commissioner is instructed to request missing treatment records and
complete RFC reports from plaintiff’s treating source(s), and/or to order consultative examinations
or medical expert testimony, sufficient to permit the reconsideration of plaintiff’s claim in its
entirety. Such reconsideration should include reassessment of the severity of plaintiff’s alleged
visual impairment, and of the limitations imposed by plaintiff’s cardiac impairments and visual
impairment, if any, upon her ability to perform work-related functions.
IT IS SO ORDERED.
Dated: Rochester, New York
May 9, 2022.
DAVID G. LARIMER
United States District Judge
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