Case Name in Social Security Case - Unavailable

UNITED STATES DISTRICT COURT
DISTRICT OF CONNECTICUT
ROXANNE C.1,
Plaintiff,
v.
FRANK BISIGNANO, Commissioner of
Social Security,
Defendant.
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3:25-CV-01621 (SVN)
October 13, 2026
RULING ON PLAINTIFF’S MOTION TO REVERSE OR REMAND AND
DEFENDANT’S MOTION TO AFFIRM DECISION OF COMMISSIONER
Sarala V. Nagala, United States District Judge.
Plaintiff filed an application for Supplemental Security Income under Title II of the Social
Security Act, alleging a disability beginning January 12, 2021. Tr., ECF No. 13, at 23. Plaintiff
appeals the unfavorable decision of an Administrative Law Judge (“ALJ”) to this Court.
Specifically, Plaintiff argues that the ALJ’s decision that her mental impairments do not meet or
medically equal a listed impairment is not supported by substantial evidence; that the ALJ erred in
assessing medical opinions for purposes of formulating the residual functional capacity (“RFC”);
and that the ALJ inadequately formulated the RFC. For the following reasons, Plaintiff’s motion
to reverse, or in the alternative, remand, is GRANTED, and the Commissioner’s motion to affirm
the decision of the Commissioner is DENIED.
I. 	BACKGROUND
The Court will assume the parties’ familiarity with Plaintiff’s medical history, as
summarized in her motion, Pl’s Br., ECF No. 15-1 at 3–13, which the Commissioner adopts and
1 In opinions issued in cases filed pursuant to § 205(g) of the Social Security Act, 42 U.S.C § 405(g), this Court will
identify and reference any non-governmental party solely by first name and last initial, in order to protect the privacy
interest of social security litigants while maintaining public access to judicial records. See Standing Order – Social
Security Cases (D. Conn. Jan. 8, 2021).
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supplements, Def.’s Br., ECF No. 19 at 2–5, and which the Court adopts and incorporates by
reference. The Court will also assume familiarity with the five sequential steps used in the analysis
of disability claims, the ALJ’s opinion, and the record. The Court will only cite portions of the
record and the legal standards necessary to explain its decision.
II. 	LEGAL STANDARD
It is well-settled that a district court will reverse the decision of the Commissioner only
when it is based upon legal error or when it is not supported by substantial evidence in the record.
See, e.g., Greek v. Colvin, 802 F.3d 370, 374–75 (2d Cir. 2015) (per curiam); 42 U.S.C. § 405(g)
(“The 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. It means
such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.”
Talavera v. Astrue, 697 F.3d 145, 151 (2d Cir. 2012) (internal quotation marks and citation
omitted). “If there is substantial evidence to support the [Commissioner’s] determination, it must
be upheld.” Selian v. Astrue, 708 F.3d 409, 417 (2d Cir. 2013) (per curiam) (internal quotation
marks and citation omitted). Put another way, “once an ALJ finds facts,” a court may “reject those
facts ‘only if a reasonable factfinder would have to conclude otherwise.’” 	Brault v. Soc. Sec.
Admin., Comm’r, 683 F.3d 443, 448 (2d Cir. 2012) (emphasis in original) (quoting Warren v.
Shalala, 29 F.3d 1287, 1290 (8th Cir. 1994)).
III. 	DISCUSSION
The Court concludes that Plaintiff’s motion to reverse the Commissioner’s decision must
be granted, and the Commissioner’s decision to affirm should be denied.
At the first step of the sequential evaluation process, the ALJ determined that Plaintiff had
not engaged in substantial gainful activity since her SSI application date, January 12, 2021. Tr.
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25. 	At the second step, the ALJ determined that Plaintiff’s schizoaffective disorder, bipolar
disorder, and anxiety disorder were severe impairments, and that Plaintiff’s asthma, carpal tunnel
syndrome, and stage 1 breast cancer were non-severe impairments.2 Tr. 25–26. At step three, the
ALJ found that these impairments—whether considered together or individually—did not meet or
medically equal any listed impairment. Tr. 26–28. At step four, the ALJ determined that Plaintiff
has RFC to perform work with certain limitations based only on her mental impairments. Tr. 28–
33.
The Court focuses its inquiry solely on the grounds challenged by Plaintiff, because
Plaintiff has waived any arguments as to other aspects of the ALJ’s decision. See Vilardi v. Astrue,
447 F. App’x 271, 272 n.2 (2d Cir. 2012) (summary order). First, Plaintiff argues that the ALJ’s
conclusion at step three was wrong because her impairments meet or equal the severity of listing
12.03. 	ECF No. 15-1 at 21 (citing 20 C.F.R. Part 404, Subpart P, App’x 1, at 12.03). 	Second,
Plaintiff challenges the ALJ’s finding with respect to her capacity for social interactions, and,
relatedly, the ALJ’s finding that her treating provider’s opinions are unpersuasive. Id. at 22–29.
Third, Plaintiff argues that the ALJ got her RFC description wrong and proposes an alternative.
Id. at 29–32. The Court addresses these arguments in turn. Although the Court ultimately finds
the vast majority of Plaintiff’s arguments unavailing, it grants her motion to remand because of
errors made by the ALJ in formulating the RFC.
A. Impairment Listing 12.03
First, the Court concludes that substantial evidence supports the ALJ’s determination that
Plaintiff’s impairments did not satisfy the severity criteria of listing 12.03.
2 The ALJ noted that these non-severe impairments “have caused only a slight abnormality or a combination of slight
abnormalities that would have no more than minimally effected claimant’s ability to meet the basic demands of work
activity.” Tr. 26.
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In order to satisfy the criteria of listing 12.03, Plaintiff bears the burden of demonstrating
that her diagnoses met all of the standards set in either paragraphs A and B or paragraphs A and C
of the listing. 	See 20 C.F.R. Part 404, Subpart P, App’x 1, at 12.03; Otts v. Comm’r of Soc.
Security, 249 F. App’x 887, 888 (2d Cir. 2007) (summary order). The ALJ found that Plaintiff’s
diagnoses met the criteria of paragraph A (which includes medical documentation of delusions or
hallucinations), but found that Plaintiff failed to meet the criteria of either paragraph B or
paragraph C. 	See Tr. 26–28. 	Here, the state agency psychological consultants (“SAPCs”), Dr.
Warren and Dr. Fiore, made key findings demonstrating that Plaintiff failed to meet the criteria of
both paragraphs B and C. 	“Courts have long held that the opinions of” state agency consultants
“may provide substantial evidence for a finding by the ALJ.” Jeremy B. v. Comm’r of Soc. Sec.,
No. 6:21-CV-903 (GTS/DJS), 2023 WL 2838052, at *5 (N.D.N.Y. Jan. 12, 2023), report and
recommendation adopted, 2023 WL 2386282; see also Mongeur v. Heckler, 722 F.2d 1033, 1039
(2d Cir. 1983) (noting that “the report of a consultative physician may constitute” substantial
evidence overriding other medical evidence). The SAPCs found that Plaintiff had no more than
moderate limitations with respect to paragraph B’s enumerated areas of mental functioning,3
falling short of the required “extreme” or “marked” limitation findings. Tr. 85, 94; 20 C.F.R. Part
404, Subpart P, App’x 1, at 12.03. 	Likewise, Dr. Warren and Dr. Fiore found that Plaintiff’s
impairments did not “establish the presence of [paragraph] ‘C’ Criteria.” Tr. 85, 94.
Additionally, the ALJ cited specific evidence in support of his findings with respect to each
of paragraph B’s areas of mental functioning. Tr. 26–28. While Plaintiff favors other evidence
and the opinions of other providers, see ECF No. 15-1 at 18–21, it is within the ALJ’s discretion
to resolve conflicts in the evidence. 	See Schaal v. Apfel, 134 F.3d 496, 504 (2d Cir. 1998);
3 These are the ability to (1) understand, remember, or apply information; (2) interact with others; (3) concentrate,
persist, or maintain pace; and (4) adapt or manage oneself.
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McIntyre v. Colvin, 758 F.3d 146, 149 (2d Cir. 2014) (in cases where “the evidence is susceptible
to more than one rational interpretation . . . the Commissioner’s conclusion must be upheld”);
Trvien K. v. Comm’r of Soc. Sec., No. 1:22-CV-00476 (JGW), 2024 WL 4753234, at *4 (W.D.N.Y.
Nov. 12, 2024) (ALJ “did not mischaracterize the record by ignoring evidence that could have
resulted in a different finding”). In light of the SAPC reports and the record evidence as cited by
the ALJ, there is adequate evidence to reasonably conclude that Plaintiff failed to satisfy paragraph
B’s criteria. See Talavera, 697 F.3d at 151.
The ALJ also concluded that Plaintiff does not satisfy paragraph C’s requirement that she
“rely, on an ongoing basis, upon medical treatment, mental health therapy, psychosocial supports,
or a highly structured environment to diminish the signs and symptoms of her mental disorder.”
Tr. 28 (citing 20 C.F.R., Part 404, Subpart P, App’x 1, at 12.00(G)(2)(b)). This criteria is satisfied
when the claimant receives ongoing medical treatment “with a frequency consistent with accepted
medical practice for the type of treatment or evaluation required for your medical condition.” 20
C.F.R., Part 404, Subpart P, App’x 1, at 12.00(G)(2)(b). Although the ALJ did not cite to specific
evidence at this portion of the decision, the SAPC reports, together with other evidence addressed
in the ALJ’s decision, provide an adequate basis for the conclusion. 	See Mongeur, 722 F.2d at
1040 (“[W]e would not remand where ‘we were able to look to other portions of the ALJ’s decision
and to clearly credible evidence in finding that his determination was supported by substantial
evidence.’”) (quoting Berry v. Schweiker, 675 F.2d 464, 469 (2d Cir. 1982)). 	For example, the
ALJ observed that “[t]he claimant has not been psychiatrically hospitalized or been referred for
intensive outpatient treatment,” Tr. 27, that “claimant’s treatment records end [in September
2022], and, thus, it is unclear how the claimant’s condition responded to medication adjustments,
which proved successful in the past,” id. at 30, and that, generally, “the claimant’s medical
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management and psychotherapy notes are lacking in objective clinical testing and observation and
instead rely almost entirely on the claimant’s self-reports,” id. at 27.4
Plaintiff argues that she saw a Licensed Professional Counselor (Richard Dunn) one to two
times per month from June 2018 through February 2023, Tr. 899, and that she took medications
over the relevant period.5 But the ALJ is in a superior position to weigh the evidence regarding
whether such treatment was consistent with accepted medical practice for Plaintiff’s conditions.
Where “credible evidence indicate[s] that the plaintiff did not meet the required criteria,” there is
no basis for remand, even if the ALJ does not specifically address paragraph C criteria. 	Handau
v. Saul, No. 3:19 CV 616 (RMS), 2020 WL 4218229, at *10 (D. Conn. July 23, 2020) (citing
Schildwachter v. Berryhill, No. 17-CV-7277 (SN), 2019 WL 1116256, at *7 (S.D.N.Y. Feb. 8,
2019)).6
Because there is sufficient evidence to reasonably conclude that Plaintiff failed to meet the
requirements of either paragraph B or C in listing 12.03, the ALJ reasonably concluded that
Plaintiff’s impairments do not meet or medically equal the severity of listing 12.03.
B. Residual Functional Capacity Findings
Second, Plaintiff argues that the ALJ did not appropriately weigh medical opinions in the
record in determining Plaintiff’s RFC. See ECF No. 15-1 at 22–29. The Court concludes that the
4 As Defendant points out, ECF No. 19 at 8, the ALJ also notes that claimant traveled out of state multiple times,
visited family members, and attended both a 4th of July celebration and her nephew’s football game, which undercuts
Plaintiff’s assertion that she required support for “even the most basic activities of daily living,” id., and is relevant to
determining the level of medical care Plaintiff required.
5 See, e.g., Tr. 408 (notes Plaintiff started Lithium medication but would continue it only at bedtime); Tr. 414 (notes
Plaintiff restarted Lithium medication); Tr. 420, 490 (reflecting Risperidone, Trazodone, Zoloft, and Lithium
prescriptions).
6 In any event, Plaintiff has not demonstrated the second paragraph C criteria of only marginal adjustment, which is
defined as “minimal capacity to adapt to changes in [her] environment or to demands that are not already part of [her]
daily life.” 20 C.F.R., Part 404, Subpart P, App’x 1, at 12.00(G)(2)(c). The evidence does not evince, for instance,
that “changes or increased demands” led to “deterioration” in Plaintiff’s functioning, id., given that she remained able
to travel out-of-state, visit family members, and attend holiday celebrations and sporting events.
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ALJ permissibly (1) departed from the SAPCs’ assessment of Plaintiff’s functional capacity for
social interaction and (2) concluded that Mr. Dunn’s report was unpersuasive.
An ALJ is charged with evaluating a number of factors in determining the weight to give
a medical opinion—most important among them are the opinion’s consistency and supportability.
20 C.F.R. § 404.1520c(b). These factors reflect that (1) “[t]he more relevant the objective medical
evidence and supporting explanations presented by a medical source are” in support of the medical
opinion, and (2) “[t]he more consistent a medical opinion . . . is with evidence from other” sources,
the more persuasive the opinion is. Id. § 404.1420c(c)(2).
In determining Plaintiff’s RFC, the ALJ found that Plaintiff could perform a full range of
work with certain limitations. Tr. 32. As relevant here, two such limitations were that Plaintiff
could have only “brief, incidental contact with the general public,” and “only occasional
interactions with co-workers and supervisors.” Tr. 32, 35. In reaching this conclusion, the ALJ
considered three assessments of Plaintiff’s mental functional capacity: two by the SAPCs, and one
by Mr. Dunn. 	The ALJ found that the SAPCs’ assessments were persuasive, except insofar as
they opine “that the claimant is limited to superficial contact with co-workers and supervisors,”
but did not find Mr. Dunn’s assessment persuasive. 	Tr. 32. 	Plaintiff takes issue with these
conclusions.
The Court finds that the ALJ’s departure from the SAPC assessments was permissible.
Even though an “ALJ’s conclusion may not perfectly correspond with any of the opinions of
medical sources cited in his decision, he [is] entitled to 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). That is precisely what the ALJ did here. Specifically, the ALJ acknowledged
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that a limitation to superficial contact “finds some support in the evidence,”7 but found that this
limitation was not consistent with evidence submitted at the hearing stage, which was not
considered by the SAPCs. Tr. 36; see also Tr. 311 (requesting additional time to submit medical
records at the hearing). Crucially, the ALJ identified evidence tending to show that—once Plaintiff
restarted treatment in 2021—Plaintiff became more social and outgoing. See generally Tr. 31; Tr.
565–66 (July 2021 treatment note stating that Plaintiff planned to go to Lake Compounce with
family over the weekend and spent time with her niece the weekend prior, and that her auditory
hallucinations were not occurring as often); Tr. 668–69 (September 2021 treatment note stating:
“Does not feel anything is missing in her life. Spending more time w/ Niece and visited her sister
. . . went to Lake Compounce w/ family, but left early – too crowded. Attended Nephew’s football
games. Restarted going on walks w/ her mom.”); Tr. 690 (October 2021 treatment note reporting
that Plaintiff “[w]ent to see grand-niece’s cheerleading competition. Trying to get out of the home
2x/wk.”); Tr. 806 (Plaintiff “spent July 4th enjoying picnic food with family.”); Tr. 591 (November
2021 treatment note regarding Plaintiff’s participation in “Thanksgiving festivities,”); Tr. 601–02
(December 2021 treatment note relating that Plaintiff traveled to Florida with her family and
“looks forward to the holidays”); Tr. 613 (December 2021 treatment note recognizing that she “did
better at coping with anxiety in FL than her trip to MA” and that her“[b]est accomplishment of
this yr was getting out more often w/ her mom”).
Additionally, contrary to Plaintiff’s assertions, the ALJ did consider the longitudinal
medical evidence from 2022. 	The ALJ considered that Plaintiff reported increased auditory
hallucinations in March of 2022, but found that her medications were adjusted “to good effect” as
7 Plaintiff presents evidence in support of this alternative conclusion. See ECF No. 15-1, at 22–23. But—again—
the existence of evidence that could support an alternative conclusion is not a basis for remand, especially where the
ALJ found such evidence as lacking credibility/unpersuasive. See Tr. 27, 36 (noting that various records reflect
claimant’s “subjective” reports that are inconsistent with other portions of the record).
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a result. 	Tr. 30. 	And although Plaintiff reported intensifying auditory hallucinations despite
adherence to her medications in September of 2022, the ALJ noted that Plaintiff’s treatment
records end at that date, so he was unable to assess how her condition responded to medication
adjustments, which had proved successful in the past. Id.
Thus, the ALJ’s decision to give less weight to the SAPC’s opinions was appropriate,
because those opinions were based on incomplete records, and therefore were not consistent with
the record as a whole (which the ALJ did consider). 	The ALJ’s decision to limit the weight of
these opinions in certain respects thus aligns with the standards governing the ALJ assessment of
medical opinions. Although Plaintiff takes issue with the ALJ’s common-sense conclusion that
Plaintiff could function around people with whom she was familiar and that she would be expected
to be familiar with coworkers and supervisors, she does not explain how the ALJ’s RFC—which,
indeed, limited her to only brief, incidental contact with the general public and only occasional
interactions with co-workers and supervisors—was flawed because of this conclusion.
The Court further concludes that the ALJ reasonably assessed Mr. Dunn’s opinion as
having little persuasive value. ECF No. 15-1 at 25; see generally Tr. 899–905 (Dunn Opinion).
The ALJ explained that Mr. Dunn’s opinion suffers from a lack of consistency with the record,
and indeed, “find[s] little support in his [own] treatment records,” Tr. 13, which “show the
[Plaintiff’s] condition is stable at her baseline level of functioning, that her symptoms improved
with medication, that she visited and socialized with family members, was able to travel to
Massachusetts and Florida, denied stressors, and that her activities – such as doing crossword
puzzles and tabletop puzzles – indicate she can perform simple work.” 	Tr. 32. 	See Medina v.
Comm’r of Soc. Sec., 831 F. App’x 35, 36 (2d Cir. 2020) (finding ALJ’s disfavoring of treating
physician’s opinion appropriate where “[t]he ALJ observed that [the treating physician’s]
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assessment of [Plaintiff’s] limitations was inconsistent with [the treating physician’s] own
treatment notes and [Plaintiff’s] self-report of her activities of daily living”). Further, the ALJ
concluded that because many of Mr. Dunn’s records that would support the opinion do not reflect
objective medical evidence but, rather, “claimant’s subjective reports,” Tr. 32, the opinion lacks
support. Thus, with the entire record in mind, the ALJ appropriately addressed the questions of
supportability and consistency to conclude that Mr. Dunn’s opinion is unpersuasive.
C. The Residual Functional Capacity Description
Finally, the Court concludes that, although it must defer to the ALJ’s resolution of
conflicting evidence to craft the RFC definition, it must remand to require consideration of
Plaintiff’s non-severe impairments.
The ALJ is required to formulate the RFC based on all relevant evidence in the record. See
20 C.F.R. § 404.1545(a); Morales v. Berryhill, 484 F. Supp. 3d 130, 145 (S.D.N.Y. 2020) (“The
RFC is a function-by-function assessment based upon all of the relevant evidence of an
individual’s ability to do work-related activities.”) (citation omitted). “In practice, administrative
law judges rely principally on medical source opinion and subjective testimony when assessing
impaired individuals’ ability to engage in work-related activities. Inevitably, they must weigh the
credibility of that evidence.” Casey v. Comm’r of Soc. Sec., No. 7:13-CV-947, 2015 WL 5512602,
at *10 (N.D.N.Y. Sept. 15, 2015)
Here, the ALJ’s formulation of the RFC engages medical source opinion, medical records,
and Plaintiff’s testimony. 	Tr. 28–33. 	Plaintiff argues that records 	reflecting “periodic
exacerbation of” mental-health related symptoms, “documented medication side effects,” and a
sedentary lifestyle supported inclusion of different RFC limitations. 	ECF 15-1 at 30–32. 	But,
again, the Court’s role is not to weigh the evidence when the ALJ has already done so. See Smith
v. Berryhill, 740 F. App’x 721, 726 (2d Cir. 2018); Vincent v. Shalala, 830 F. Supp. 126, 133
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(N.D.N.Y. 1993). 	The ALJ formulated an RFC reflecting his assessment of the evidence as a
whole. 	See Tr. 33 ([T]he undersigned finds that the claimant’s medically determinable
impairments could reasonably be expected to cause the alleged symptoms; however, the claimant’s
statements regarding the intensity, persistence, and limiting effects of these symptoms are not
entirely consistent with the medical evidence and other evidence in the record.”). With respect to
Plaintiff’s mental impairments, RFC assessment includes the required narrative discussion
describing how the evidence supports each conclusion, explaining why it departs from medical
sources. See SSR 96-8P, 1996 WL 374184, at *7 (July 2, 1996).
However, the Court must remand to require the ALJ’s consideration of Plaintiff’s non-
severe impairments in formulating the RFC. The ALJ must “consider all of [Plainitff’s] medically
determinable impairments of which [he is] aware, including [Plaintiff’s] medically determinable
impairments that are not ‘severe’ . . . when [he] assess[es] [Plaintiff’s] residual functional
capacity.” 20 C.F.R. § 404.1545(a)(2). As articulated in Parker-Grose v. Astrue, 462 F. App’x 16,
18 (2d Cir. 2012), when an ALJ fails to consider any kind of impairment in assessing the residual
functional capacity, remand is warranted. See id. (“[E]ven if this Court concluded that substantial
evidence supports the ALJ’s finding that [Plaintiff’s] mental impairment was nonsevere, it would
still be necessary to remand this case for further consideration because the ALJ failed to account
[Plaintiff’s] mental limitations when determining her RFC.”); see also, e.g., Coleman v. Kijakazi,
No. 3:20-CV-01588 (VLB), 2022 WL 766127, at *9 (D. Conn. Mar. 14, 2022).
Here, the ALJ makes no specific mention of Plaintiff’s non-severe impairments in the RFC
analysis. Although the ALJ notes that “[t]he longitudinal records reveal no convincing evidence
that the claimant has physical work-related limitations” in the RFC analysis, Tr. 29, the ALJ earlier
acknowledges that Plaintiff’s non-severe impairments may affect work activities, albeit minimally,
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Tr. 26. The record contains evidence that Plaintiff suffers from fatigue, leg cramps, and shortness
of breath, which Plaintiff attributes to side effects from her cancer-related chemotherapy
medication. 	Tr. 899 (Dunn Opinion); 759, 767 (referencing “lower extremity charley horses”).
Plaintiff also notes that she spends most of her time in sedentary positions. Respondent does not
contest Plaintiff’s assertion that the ALJ failed to account for possible exertional limitations in the
RFC. In any case, the Code of Federal Regulations and Second Circuit case law make clear that
the ALJ is required to re-engage with these impairments at the RFC definition stage, which he did
not meaningfully do. A boilerplate statement that the ALJ has considered the functional limitations
resulting from all severe and non-severe impairments, see id. 26, does not suffice. Accordingly,
the Court remands this case so the ALJ may ensure all of Plaintiff’s impairments, severe and non-
severe, are considered in formulating the RFC.
IV. 	CONCLUSION
For the reasons described herein, Plaintiff’s motion to reverse or remand is GRANTED
and Defendant’s motion to affirm the Commissioner’s decision is DENIED. The Clerk is directed
to enter judgment for Plaintiff and close this case.
SO ORDERED at Hartford, Connecticut, this 13th day of October, 2026.
/s/ Sarala V. Nagala
SARALA V. NAGALA
UNITED STATES DISTRICT JUDGE
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