STEVEN R., Plaintiff, v. COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, Defendant.
Case 1:23-cv-06911-HG
UNITED STATES DISTRICT COURT EASTERN DISTRICT OF NEW YORK
March 11, 2025
HECTOR GONZALEZ, United States District Judge
MEMORANDUM & ORDER
Plaintiff Steven R.1 seeks judicial review, pursuant to
BACKGROUND
Plaintiff first applied for DIB on November 4, 2020, alleging the onset of disability on March 15, 2020, based on: “drop foot,”2 “status post lumbar microdiscectomy for lumbar herniation,” “degenerative disc disease,” “spinal stenosis,” “scoliosis,” “chronic kidney disease,”
On May 19, 2022, the ALJ issued her decision, determining that Plaintiff was not disabled within the meaning of the Social Security Act since March 15, 2020. Id. at 10–19. The ALJ reached the following conclusions:
- The claimant meets the insured status requirements of the Social Security Act through December 31, 2024.
- The claimant has not engaged in substantial gainful activity since March 15, 2020, the alleged onset date (
20 CFR 404.1571 et seq. ). - The claimant has the following severe impairments: lumbar spine degenerative disc disease with foot drop, status post lumbar microdiscectomy, scoliosis, chronic sinusitis, obstructive sleep apnea (
20 CFR 404.1520(c) ). - The claimant does not have an impairment or combination of impairments that meets or medically equals the severity of one of the listed impairments in
20 CFR Part 404, Subpart P, Appendix 1 (20 CFR 404.1520(d) ,404.1525 and404.1526 ). - After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform light work as defined in
20 CFR 404.1567(b) except: he can stand and/or walk with normal breaks for a total for both of 6 hours in an 8-hour workday, sit with normal breaks for 6 hours in an 8-hour workday, cannot perform push/pull or foot control operation with the right lower extremity, can occasionally climb ramps or stairs, and never climb ladders, ropes or scaffolds, can occasionally balance or stoop, and never kneel, crouch or crawl, can tolerate no occasional exposure topulmonary irritants; and must avoid concentrated exposure to unprotected heights or operating heavy or hazardous equipment. - The claimant is capable of performing past relevant work as a Security Guard. This work does not require the performance of work-related activities precluded by the claimant‘s residual functional capacity (
20 CFR 404.1565 ). - The claimant has not been under a disability, as defined in the Social Security Act, from March 15, 2020, through the date of this decision (
20 CFR 404.1520(f) ).
Id. at 12–19. The SSA‘s Appeals Council denied Plaintiff‘s request for review on July 18, 2023, rendering the ALJ‘s decision the final decision of the Commissioner. Id. at 1–3.
Plaintiff then sought review in this Court by initiating this action on September 18, 2023. See ECF No. 1. On February 2, 2024, Plaintiff filed his motion. See ECF No. 8. On March 21, 2024, Defendant filed its motion. See ECF No. 11. Although the Court provided Plaintiff with an opportunity to file a reply, he did not do so. See Mar. 15, 2024, Text Order.
LEGAL STANDARD
When a plaintiff challenges an ALJ‘s decision as unsupported by substantial evidence, as Plaintiff does here, the Court must “conduct a plenary review of the administrative record” and determine “whether the ALJ applied the correct legal standards and whether the ALJ‘s determination is supported by substantial evidence.” Rucker v. Kijakazi, 48 F.4th 86, 90–91 (2d Cir. 2022). “The substantial evidence standard is a very deferential standard of review—even more so than the clearly erroneous standard.” Schillo v. Kijakazi, 31 F.4th 64, 74 (2d Cir. 2022). But the standard is “not merely hortatory: It 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). The Court is therefore “required to examine the entire record, including contradictory evidence and evidence from which conflicting inferences can be drawn.” Schillo, 31 F.4th at 74. Once an ALJ has made findings of fact, however, the Court “can reject those facts only if a reasonable factfinder would have to conclude otherwise.” Id. (emphasis in original). Put another way, “[i]f evidence is susceptible to more than one rational interpretation,
DISCUSSION
On appeal Plaintiff raises two issues. First, he argues that the ALJ erred by failing to find Plaintiff‘s “chronic kidney stones” to be a severe impairment. See ECF No. 8 at 6. Second, he takes issue with the ALJ‘s assessment of his residual functional capacity (“RFC“). See id. at 6–7. The Court begins its analysis with a brief discussion of how the ALJ makes a disability determination, including as applied to this case, and then addresses Plaintiff‘s challenges.
A. Determining RFC and Disability
ALJs must employ a “five-step sequential evaluation process” to determine whether a claimant is disabled, proceeding through each step until a determination can be reached.
At step one, the ALJ considers the claimant‘s work activity.
In this case, the ALJ ended her analysis at step four, concluding that in light of the previously described RFC, Plaintiff “is capable of performing past relevant work as a security guard” because that work “does not require the performance of work-related activities precluded by [his] [RFC].” AR at 18.
B. Challenges to the RFC
The Court now addresses each of Plaintiff‘s challenges to the ALJ‘s decision. The Court easily disposes of Plaintiff‘s challenges, which are set forth in a perfunctory two pages of briefing. See ECF No. 8 at 6-7.
i. Chronic Kidney Disease
Plaintiff first takes issue with the ALJ‘s decision not to include his chronic kidney disease as a severe impairment at step two. See ECF No. 8 at 6. For context, the ALJ provided the following analysis of the kidney disease at that step:
The record indicates the claimant has a significant history of kidney stones. For longitudinal purposes, the record indicates the claimant was receiving treatment relating to kidney stones in 2007. (16F/15). In recent testing, the claimant had right flank pain and underwent radiographic testing which revealed mild right hydroureteronephrosis, right renal subcapsular collection and bilateral non obstructing renal calculi. Furthermore, the claimant was noted to have kidney stones. (23F). However, there is no indication that the claimant required significant treatment. The record notes the claimant was able to pass kidney stones without surgical intervention on occasion. Additionally, when surgical intervention was discussed with the claimant in June 2021, he opted to wait until after he returned from his vacation and to return for a follow-up visit in September 2021 to discuss further. (16F/202). [T]he record is devoid of any evidence to support that the claimant‘s ... chronic kidney disease more than minimally affected the claimant‘s ability to perform basic work activities.
AR at 12-13. Plaintiff specifically takes issue with the ALJ‘s conclusion that Plaintiff did not “require[] significant treatment” for the kidney disease. ECF No. 8 at 6. He argues that “the record establishes that [he] suffered [from] chronic kidney stones for several years and require[ed] regular treatment in 2020 and 2021 which necessitated his back surgery be delayed” as well as hospitalization. Id. Defendant disagrees and points to various pieces of evidence in support of the ALJ‘s position. See ECF No. 12-1 at 20–23.
First, the ALJ acknowledged the relevant medical evidence. That included evidence from 2007, specifically a CT scan reading showing kidney stones. See AR at 12, 846.7 But Plaintiff does not explain how that evidence from well before the alleged onset date should inform the step two analysis. See Angele J. W. v. Comm‘r of Soc. Sec., No. 23-cv-00824, 2024 WL 4204301, at *5 (N.D.N.Y. July 24, 2024) (“Medical evidence that predates the alleged disability onset date is ordinarily not relevant to evaluating a claimant‘s disability.“), report and recommendation adopted, 2024 WL 4204017 (N.D.N.Y. Sept. 16, 2024). That concern is
Second, to the extent Plaintiff does try to connect the kidney condition evidence to severity, he misconstrues the record. For the reasons just discussed, his bare argument that he received “regular treatment in 2020 and 2021” fails to satisfy his burden. ECF No. 8 at 6. To be sure, Plaintiff says that treatment required that “his back surgery be delayed.” Id. And to substantiate that claim, he cites to over 200 pages of the AR without any specification. Id. (citing AR at 832–1034). However, the Court has combed through the AR, including the range Plaintiff identifies (the vast majority of which predates the alleged onset date, and only some of which relates to kidney stone treatment), and finds his characterization of the severity of his symptoms lacks evidentiary support. With regard to the delayed back surgery, the Court agrees with Defendant that Plaintiff appears to refer to a disc herniation surgery scheduled for June 12, 2020. Id. at 1019. On that day, Plaintiff reported “significant right lower flank pain.” Id. After a CT scan revealed a kidney stone, see id. at 1009, 1019, the surgery was indeed canceled and Plaintiff had chills and a fever the next day, id. at 1011, but he stated that his pain “resolved later that day [of the surgery],” he had no additional “constitutional complaints” between then and a subsequent doctor‘s visit on July 24, 2020, and he believed that he had passed the stone, id. at 1019.
ii. RFC
Plaintiff also challenges the ALJ‘s assessment of his “light work” RFC. See ECF No. 8 at 6. The Court groups his challenges into two categories. First, he makes a fleeting reference to the ALJ‘s purported “failure . . . to factor [his kidney stones] into [his] RFC.” Id. Not so. As an initial matter, the ALJ explicitly mentioned the presence of kidney stones in the RFC analysis. AR at 15. Although that discussion was not detailed, Plaintiff does not try to explain how any limitations associated with the kidney stones should have been incorporated into the RFC. See Reddy v. Comm‘r of the Soc. Sec. Admin., No. 23-cv-07947, 2025 WL 21942, at *4 (E.D.N.Y. Jan. 3, 2025) (affirming Commissioner‘s RFC determination where “[p]laintiff fail[ed] to explain
Second, Plaintiff highlights evidence of “permanent foot drop” as well as “chronic numbness in his big toes, chronic leg spasm, definitive weakness in [the] right foot, an inability to walk on [the] heels o[f] [the] right foot[,] and an antalgic gait.” ECF No. 8 at 7.8 Here, too, he does not clearly articulate how he thinks the ALJ erred—i.e., how she should have further restricted the RFC to account for these impairments. Nevertheless, he argues that “[e]very medical provider who opined on [his] RFC, including various treatment providers and the consultative examiner, indicated he was unable to engage in prolonged standing or walking,” suggesting those are the aspects of the RFC he takes issue with. ECF No. 8 at 7. As a reminder, the ALJ found in the RFC that “he can stand and/or walk with normal breaks for a total for both of 6 hours in an 8-hour workday” and “sit with normal breaks” for the same periods. AR at 14.
The Court agrees with the ALJ that Plaintiff‘s “statements concerning the intensity, persistence[,] and limiting effects of [his] symptoms,” including those made before the ALJ and now before this Court, “are not entirely consistent with the medical evidence and other evidence in the record.” Id. at 15. The ALJ considered the conditions Plaintiff raises here and correctly identified the relevant evidence, including by describing in detail the symptoms that Plaintiff suggests she gave insufficient weight to following his back surgery in June 2020. See id. at 15–16. But she also correctly identified countervailing evidence. For example, physical therapy treatment notes from November 2020 indicated that Plaintiff showed improvement despite continued difficulty with walking due to the foot drop. Id. at 15 (citing id. at 667). By January 2021, he had stopped post-surgery physical therapy and walked with no assistive device and only
Plaintiff also takes issue with the ALJ‘s assessment of the medical opinions. There are four relevant medical opinions from (1) Drs. Levit and Ahmed, the state agency consultants; (2) Dr. Guariglia, a chiropractor; (3) Dr. Fernandez, the consultative examiner; and (4) Physician Assistant Pulatov. See id. at 17–18, 60, 83. As mentioned, Plaintiff argues that “[e]very medical provider . . . indicated [that he] was unable to engage in prolonged standing or walking.” ECF No. 8 at 7. Where does that come from? Only PA Pulatov said as much, stating that Plaintiff could “[s]tand/walk” for fewer than two hours per day. AR at 487.9 Dr. Fernandez was only somewhat closer to that view, stating that Plaintiff had “moderate limitation” in “prolonged standing” or “prolonged walking.” Id. at 824. And the other medical opinions cannot be reconciled at all with Plaintiff‘s statement. Drs. Levit and Ahmed both said he could “[s]tand
Finally, Plaintiff claims that the ALJ gave improperly little weight to Dr. Fernandez‘s opinion. ECF No. 8 at 7. For context, the ALJ found the doctor‘s “vague opinion” to be “partially unpersuasive” because it was “not stated in function-by-function terms.” AR at 17. Plaintiff implies that the ALJ should not have discounted the opinion at all because it was based on the doctor‘s “entire examination of [him].” ECF No. 8 at 7. In particular, he says it should have been prioritized over the opinions of the state agency consultants, whose opinions the ALJ found “persuasive as [they were] supported by the record,” AR at 17, because those doctors did not “actually physically examine[] [him],” ECF No. 8 at 7.
As an initial matter, the Court agrees with Defendant‘s position that Plaintiff‘s argument does not prove enough. See ECF No. 12-1 at 27. In other words, even had the ALJ fully credited Dr. Fernandez‘s opinion that Plaintiff had “moderate limitation[s]” as to “prolonged standing” and “prolonged walking,” it would not automatically mean that a more restrictive RFC was required. After all, the RFC developed by the ALJ was already quite restrictive, limiting Plaintiff to light work and, as relevant here, to a total of six hours of sitting and standing, with normal breaks, in an eight-hour workday. AR at 14. The Court sees no inconsistency between that RFC and Dr. Fernandez‘s opinion, even if fully credited. As Judge Matsumoto recently explained, “Courts in the Second Circuit have consistently found that moderate limitations in a plaintiff‘s ability to perform exertional activities are consistent with an RFC for light work.” See Michalakis v. O‘Malley, No. 21-cv-2697, 2024 WL 1071991, at *10 (E.D.N.Y. Mar. 11, 2024) (collecting cases).
In any case, substantial evidence supported some discounting of Dr. Fernandez‘s opinion. See Schillo, 31 F.4th at 77–78. In doing this assessment, the ALJ was required to “consider[]
Although an explicit discussion of supportability and consistency was lacking here, see AR at 17, “a searching review of the record assures the [C]ourt that the substance of the regulation was not traversed.” See John L. M. v. Kijakazi, No. 21-cv-368, 2022 WL 3500187, at *2 (N.D.N.Y. Aug. 18, 2022) (citing Loucks v. Kijakazi, No. 21-1749, 2022 WL 2189293, at *2 (2d Cir. June 17, 2022)). Importantly, as Defendant notes, see ECF No. 12-1 at 27–28, the ALJ found Dr. Fernandez‘s position only “partially unpersuasive,” AR at 17.10 That assessment to mostly credit the opinion necessarily reflected an assessment of supportability,
The Court also rejects Plaintiff‘s argument that the ALJ should have prioritized Dr. Fernandez‘s opinion over the state agency consultants’ opinions because he “actually physically examined [Plaintiff].” ECF No. 8 at 7. As is now well-established, there is no longer a “hierarchy of medical sources” in Social Security cases and “the ALJ [does] not defer or give any specific evidentiary weight, including controlling weight, to any medical opinion.” Colgan, 22 F.4th at 365 (citing
CONCLUSION
In this case, the ALJ‘s decision was amply supported by substantial evidence. Accordingly, Plaintiff‘s motion for judgment on the pleadings is denied, Defendant‘s motion is
SO ORDERED.
/s/ Hector Gonzalez
HECTOR GONZALEZ
United States District Judge
Dated: Brooklyn, New York
March 11, 2025
