Opinions and documents
UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF NEW YORK
_________________________________
BRENDA W.,
Plaintiff,
Case No. 1:22-cv-00803-TPK
v.
COMMISSIONER OF SOCIAL OPINION AND ORDER
SECURITY,
Defendant.
OPINION AND ORDER
This case is before the Court for the third time to consider a final decision of the
Commissioner of Social Security which denied Plaintiff’s application for a closed period of
social security disability benefits. On March 5, 2019, the Court resolved Case No. 1:18-cv-00590
by ordering a remand for further proceedings, something that the parties had stipulated to. The
Commissioner again denied benefits, Plaintiff again appealed, and in an order dated April 26,
2021 filed in Case No. 1:20-cv-00657, the Court issued its second remand. Following that
remand, an Administrative Law Judge issued an unfavorable decision on June 27, 2022, which
constituted the Commissioner’s final decision. After filing the complaint in this case, Plaintiff
moved for judgment on the pleadings (Doc. 9) and the Commissioner filed a similar motion
(Doc. 12). For the following reasons, the Court will DENY Plaintiff’s motion for judgment on
the pleadings, GRANT the Commissioner’s motion, and DIRECT the Clerk to enter judgment
in favor of the defendant Commissioner.
I. BACKGROUND
Plaintiff applied for social security disability benefits on November 3, 2014, alleging that
she became disabled on July 3, 2012. After initial administrative denials of her claim, Plaintiff
appeared at a hearing before an Administrative Law on November 21, 2016. The ALJ issued a
decision on April 5, 2017, finding that Plaintiff became disabled, and was entitled to benefits, as
of January 25, 2017, but not before. After the Court remanded the case in 2019, a second
administrative hearing was held on December 18, 2019, following which an unfavorable
decision was issued on February 3, 2020. The second remand followed, and a third
administrative hearing was held on February 3, 2022, followed by another unfavorable decision
dated June 27, 2022. Plaintiff, a medical expert, and a vocational expert all testified at the most
recent hearing.
In the ALJ’s June 27, 2022 decision, he found, first, that Plaintiff last met the insured
status requirements of the Social Security Act on December 31, 2017, and that she did not
engaged in substantial gainful activity during the period in question. Next, he determined that
she suffered from severe impairments including obesity, lower extremity edema, degenerative
disc disease of the cervical, thoracic, and lumbar spine, and multiple sclerosis. He further found
that none of these impairments, considered singly or in combination, met the criteria for
disability under the Listing of Impairments.
Moving to the next step of the sequential evaluation process, the ALJ concluded that
Plaintiff could perform sedentary work up through January 25, 2017. However, she had to
elevate her legs up to 90 degrees for 50% of the time while seated and had to be able to alternate
between sitting and standing every hour without being off task. Further, she could climb ramps
and stairs only occasionally, could frequently stoop, balance, and crouch, could never crawl,
could not climb ropes, ladders, or scaffolds, and could not work at unprotected heights.
The ALJ found that with these limitations, Plaintiff could not do her past relevant work
as tractor-trailer truck driver, a contact representative, or a credit and loan collection supervisor.
However, based on the vocational testimony, he determined that she could perform sedentary
jobs such as addresser, document preparer, or charge account clerk. He also found that these
jobs existed in significant numbers in the national economy. As a result, the ALJ concluded that
Plaintiff was not under a disability as defined in the Social Security Act at any time between her
alleged onset date and January 25, 2017.
In her motion for judgment on the pleadings, Plaintiff raises a single issue, stated as
follows:
The ALJ assessed a highly specific RFC that was not based on substantial
evidence or tethered to the record.
Plaintiff’s memorandum, Doc. 9-1, at 1.
II. THE KEY EVIDENCE
A. Hearing Testimony
At the first administrative hearing, held in 2016, Plaintiff testified that she saw a number
of different doctors for different issues, including problems with her memory and pain in her
back and legs. She said her neck and back pain had increased since she was involved in a motor
vehicle accident three years before. She had also enrolled in school while working full-time but
the program took her much longer to complete than expected due to her pain causing problems
with concentration. She stopped working at a collection agency due to the mental demands of
the work, including stress, and also because of some of the physical demands of the job.
Plaintiff was next asked whether she could do a job that provided a sit/stand option and
allowed for changing positions as well. She said that when sitting, she had to elevate her legs to
relieve back pain and swelling, something she did when attending classes. She also needed to
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get up and move around every five to ten minutes. Plaintiff had been caring for her mother as
well, mainly giving her reminders and taking her laundry home. At her own house, she had to
stop doing lawn care and snow removal after the accident, and she noticed that her walking was
more limited. She also referred to having been diagnosed with multiple sclerosis and said that it
was causing more memory problems since the car accident.
The second hearing was held in 2019. There, Plaintiff said that during the relevant time
period, she had back and leg pain and could sit for only 20 minutes at a time. Moving around or
standing up helped alleviate the pain. She had balance issues when walking and also was
restricted in her lifting ability. She could climb stairs, but slowly, and said that she needed to
elevate her legs every night to reduce swelling, and also that she would keep them slightly
elevated at work. Plaintiff also said she had “brain fog” during that time and needed memory
prompts, and that she also noticed that stress seemed to aggravate her MS. Household chores,
including cooking, laundry, cleaning, and doing dishes were all very difficult for her to do.
At the third hearing, held in 2022, Plaintiff, a medical expert, and a vocational expert all
testified. Plaintiff repeated her testimony about having swelling in her legs during the relevant
time period and keeping them elevated as well as using compression wraps. She also said she
had done physical therapy but, if anything, it made her back worse. She further testified that she
used a cane for stability when walking.
The medical expert, Dr. Gaeta, said that Plaintiff’s severe impairments included multiple
sclerosis and morbid obesity. He thought she was doing well with her MS. Dr. Gaeta noted that
Plaintiff did develop some back problems after the 2014 motor vehicle accident that also radiated
into her right leg. She also had swelling in her legs on and off which was addressed by elevating
her legs as much as possible. He said that any psychological issues were beyond his area of
expertise. When further questioned about Plaintiff’s need to elevate her legs, Dr. Gaeta said that
it would be wise for her to wear support stockings, lose weight, use diuretics, and elevate her
legs “whenever she can.” (Tr. 1383). That would included during a working day, although he
said that was not specifically necessary, and he finally described her need as elevating her legs
for “[p]art of the day as possible.” (Tr. 1384). However, he did not think she would suffer
medically if she were not able to do so. Further addressing Plaintiff’s functional capacity, Dr.
Gaeta said she could lift 20 pounds, sit for six hours, stand and walk for four hours, occasionally
climb stairs, occasionally stoop, frequently balance and bend, never crawl, frequently crouch,
and avoid unprotected heights. The questioning then returned to the need for Plaintiff to elevate
her legs, and after some prolonged discussion, Dr. Gaeta said that if Plaintiff were his patient he
would advise her to do so 50% of the time if her edema were present. (Tr. 1396).
The final witness was the vocational expert, Ms. Vasishth. She agreed with prior
vocational testimony that Plaintiff had worked as a truck driver, but said that her other job,
which Plaintiff was asked to describe in more detail, was properly classified as a collection
supervisor. Ms. Vasishth was then asked how needing to elevate one’s legs for 50% of the day
would impact sedentary work, and she said that if one did not deal directly with the public in
person, it would have no impact. Next, the ALJ described a person who was limited to sedentary
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work with certain postural limitations, who needed to alternate between sitting and standing once
an hour, and who had to keep her legs elevated for 50% of the time. He asked if that person
could do Plaintiff’s past work, and the answer was no. However, Ms. Vasishth said such a
person could do jobs like addressing clerk, document preparer, or charge account clerk, and she
gave numbers for those jobs as they existed in the national economy. She further testified that
employers would tolerate an employee taking a stretch break every 20 minutes, and also that the
essential functions of each of those three jobs could be done while sitting or standing. Lastly,
she said that being off task more than 10% of the time or being absent from work more than one
day per month would not be tolerated, and that the jobs in question did not involve contact with
the public or more than routine, repetitive tasks with no production quotas.
B. Medical Evidence
Plaintiff’s argument in this case does not focus on what is in the medical record, but on
what is not there, as the Court will explain more fully below. Plaintiff has accurately
summarized the treatment records in her memorandum, and the Court will not review them in
any detail in this Opinion and Order.
C. Opinion Evidence
The primary opinion evidence in this case is Dr. Gaeta’s testimony, which is described
above. Other evidence includes a 2015 report from Dr. Miller, whose opinion as to Plaintiff’s
ability to climb stairs, work at unprotected heights, bend, lift, and carry was given significant
weight, at least to the extent that it appeared to be consistent with a limitation to sedentary work,
and an opinion from Dr. Patel stating that, at least at one point in 2016, Plaintiff was temporarily
totally disabled. The ALJ gave that opinion little weight. There were also some opinions about
Plaintiff’s psychological functioning, but they are not relevant to the issue which Plaintiff has
presented for decision.
III. STANDARD OF REVIEW
The Court of Appeals for the Second Circuit has stated that, in reviewing a final decision
of the Commissioner of Social Security on a disability issue,
“[i]t is not our function to determine de novo whether [a plaintiff] is disabled.”
Pratts v. Chater, 94 F.3d 34, 37 (2d Cir.1996). Instead, “we conduct a plenary
review of the administrative record to determine if 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); see also 42 U.S.C. § 405(a) (on judicial review, “[t]he findings
of the Commissioner of Social Security as to any fact, if supported by substantial
evidence, shall be conclusive.”).
Substantial evidence is “more than a mere scintilla.” Moran, 569 F.3d at 112
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(quotation marks omitted). “It means such relevant evidence as a reasonable mind
might accept as adequate to support a conclusion.” Id. (quotation marks omitted
and emphasis added). But it is still a very deferential standard of review—even
more so than the “clearly erroneous” standard. See Dickinson v. Zurko, 527 U.S.
150, 153, 119 S.Ct. 1816, 144 L.Ed.2d 143 (1999). The substantial evidence
standard means once an ALJ finds facts, we can reject those facts “only if a
reasonable factfinder would have to conclude otherwise.” Warren v. Shalala, 29
F.3d 1287, 1290 (8th Cir.1994) (emphasis added and quotation marks omitted);
see also Osorio v. INS, 18 F.3d 1017, 1022 (2d Cir.1994) (using the same
standard in the analogous immigration context).
Brault v. Soc. Sec. Admin., Com'r, 683 F.3d 443, 447–48 (2d Cir. 2012).
IV. DISCUSSION
Plaintiff has raised just a single issue in her memorandum, and it concerns only a handful
of conclusions reached by the ALJ about Plaintiff’s residual functional capacity. As noted
above, in addition to limiting Plaintiff to sedentary work with some postural and environmental
restrictions, the ALJ determined that Plaintiff needed to elevate her legs for 50% of the workday
and that she needed to be able to alternate between sitting and standing every hour without being
off task. Plaintiff contends that neither of these two very specific limitations are referenced in
any of the medical opinions and that the ALJ had no sound basis for imposing them. The
Commissioner, in turn, points to portions of the testimony and other evidence in arguing that the
ALJ’s conclusions enjoyed substantial support in the record and that they were not the product of
an impermissible lay interpretation of the raw medical data. For the reasons set forth below, the
Court finds the Commissioner’s argument to be the more persuasive.
It is true, as Plaintiff argues, that there are limits to an ALJ’s ability to craft specific parts
of a residual functional capacity finding when there is no direct support for those parts in the
medical evidence. At the same time, however, deviating from the expert medical testimony
concerning a claimant’s functional capacity is not always error. This Court has described the
law in this area this way:
An ALJ must “weigh all of the evidence available to make an RFC finding that
[is] consistent with the record as a whole.” Matta v. Astrue, 508 F. App'x 53, 56
(2d Cir. 2013); accord Schillo v. Kijakazi, 31 F.4th 64, 78 (2d Cir. 2022). But that
does not mean that the RFC needs to “perfectly correspond with any of the
opinions of medical sources cited in [the ALJ's] decision,” Matta, 508 F. App'x at
56, or even be based on opinion evidence, see Corbiere v. Berryhill, 760 F. App'x
54, 56 (2d Cir. 2019). As long as the ALJ considers all the medical evidence and
appropriately analyzes the medical opinions, an RFC consistent with the record is
not error. See 20 C.F.R. § 404.1545; see also Cichocki v. Astrue, 729 F.3d 172,
177 (2d Cir. 2013) (holding that remand is not necessary “[w]here an ALJ's
analysis at Step Four regarding a claimant's functional limitations and restrictions
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affords an adequate basis for meaningful judicial review, applies the proper legal
standards, and is supported by substantial evidence”).
Lee C. v. Comm'r of Soc. Sec., 2024 WL 217582, at *3 (W.D.N.Y. Jan. 19, 2024).
Turning first to the requirement that Plaintiff had to elevate her feet 50% of the time, the
Court has summarized the testimony on this subject given at the administrative hearing by Dr.
Gaeta. As noted, the ALJ directed a fair number of questions to Dr. Gaeta about this issue.
Fairly read, Dr. Gaeta’s testimony was that, for the most part, there was not an actual medical
necessity for Plaintiff to elevate her legs, but if she were his patient, he would recommend, based
on her occasional edema, that she do so 50% of the time. Plaintiff also testified that she would
keep her legs elevated when sitting either at work or in the classroom and that this helped with
the swelling. The ALJ was entitled to (and did) consider all of this testimony, and he
synthesized it by concluding that, for simplicity’s sake, a 50% restriction made the most sense.
The Court concludes that the record as a whole supports the ALJ’s decision that Plaintiff was
able to sit for prolonged periods if she had the ability to elevate her legs half of the time.
As to the determination that Plaintiff needed some variation of a sit/stand option, this
Court has addressed that issue in a very similar case. On facts that are essentially the same as
those present here, the Court said:
In this case, neither Dr. Ghazi nor consultative examiner Dr. Samuel Balderman
opined that Plaintiff required a sit/stand option. Dr. Balderman did not assess any
limitations in sitting or standing (Dkt. 6 at 487-88), while Dr. Ghazi opined that
Plaintiff was capable of sitting for six hours in an eight-hour workday without
restriction, and was capable of standing for four hours with only normal breaks
(id. at 67). However, Plaintiff testified at the hearing she can sit for “15, 20
minutes” before experiencing pain. (Id. at 54). She would then need to stand and
stretch before sitting again. (Id.). Plaintiff further testified that she could stand for
10 to 15 minutes, and by 25 minutes, her feet would be numb. (Id.). The ALJ
explained that he weighed Plaintiff's subjective complaints against the medical
assessments that noted her normal strength, reports of alleviated pain, and normal
gait. (See id. at 20). The Court cannot conclude that the ALJ's resolution of these
conflicting aspects of the record was outside his discretion. See Mary Diane K. v.
Comm'r of Soc. Sec., 541 F. Supp. 3d 270, 276 (W.D.N.Y. 2021) (“It was further
not erroneous for the ALJ to partially credit Plaintiff's testimony regarding her
own limitations and assess more restrictive manipulative and environmental
limitations than those identified by the consultative examiners.”).
Jessica Lynn J. v. Comm'r of Soc. Sec., 645 F. Supp. 3d 128, 136 (W.D.N.Y. 2022). Here, too,
the ALJ resolved a conflict between the functional capacity expressed by Dr. Gaeta and
Plaintiff’s subjective testimony as to her sitting limitations and what she needed to do to alleviate
her discomfort. He particularly noted that he had imposed these and other limitations based in
part on “her reports of physical limitations due to increased fatigue, having sharp pain in her
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back, relapsing and remitting multiple sclerosis, and lower leg edema.” (Tr 1353). Again, the
record as a whole supported this resolution, and it was therefore within the ALJ’s purview to
make.
Plaintiff has raised a third issue concerning the ALJ’s reliance on the testimony of the
vocational expert to the effect that leg elevation did not preclude the performance of the
sedentary jobs she identified. Plaintiff’s argument here is simply that she submitted evidence
from a different vocational expert which disputed this testimony. Plaintiff has not explained,
however, why the ALJ had to give greater weight to this expert’s view or why the ALJ was not
entitled to resolve the conflict in favor of the testimony given at the hearing. As the Court of
Appeals has observed, “it is up to the agency, and not this court, to weigh the conflicting
evidence in the record.” Clark v. Comm'r of Soc. Sec., 143 F.3d 115, 118 (2d Cir. 1998). This
contention lacks merit as well. Consequently, the Court finds no error here requiring reversal or
remand.
V. CONCLUSION AND ORDER
For the reasons stated above, the Court DENIES Plaintiff’s motion for judgment on the
pleadings (Doc. 9), GRANTS the Commissioner’s motion (Doc. 12), and DIRECTS the Clerk
to enter judgment in favor of the Defendant Commissioner of Social Security.
/s/ Terence P. Kemp
United States Magistrate Judge
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