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finding that the ALJ should have further developed the record where his rejection of a medical opinion had left a gap in the record
Summary of this case from Golden v. SaulOpinion
1:15-cv-00561 EAW
2016-08-31
Thomas R. COVEY, Plaintiff, v. Carolyn W. COLVIN, Acting Commissioner of Social Security, Defendant.
Lewis L. Schwartz, Lewis L. Schwartz, PLLC, Buffalo, NY, for Plaintiff. Amanda Lockshin, Sandra M. Grossfeld, Social Security Administration, Office of General Counsel, New York, NY, for Defendant.
Lewis L. Schwartz, Lewis L. Schwartz, PLLC, Buffalo, NY, for Plaintiff.Amanda Lockshin, Sandra M. Grossfeld, Social Security Administration, Office of General Counsel, New York, NY, for Defendant.
DECISION AND ORDER
ELIZABETH A. WOLFORD, United States District Judge
I. INTRODUCTION
Represented by counsel, Plaintiff Thomas R. Covey ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final decision of Carolyn W. Colvin, Acting Commissioner of Social Security ("the Commissioner"), denying Plaintiff's application for Disability Insurance Benefits ("DIB"). (Dkt. 1). Presently before the Court are the parties' opposing motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. (Dkt. 7, 12). For the reasons set forth below, the Commissioner's motion is denied, Plaintiff's motion is granted in part, and this matter is remanded for further administrative proceedings.
II. FACTUAL BACKGROUND AND PROCEDURAL HISTORY
A. Overview
On May 24, 2012, Plaintiff filed an application for DIB (Administrative Transcript (hereinafter "Tr.") at 66, 118-19). In his application, Plaintiff alleged that he had been disabled since January 2, 2004 , due to diabetes and diabetic neuropathy in his feet and hands. (Id. at 145, 169). Plaintiff's applications for DIB was initially denied on August 3, 2012. (Id. at 66-71). Plaintiff timely filed a request for a hearing before an Administrative Law Judge ("ALJ"). (Id. at 86-87). Plaintiff appeared at a hearing before Administrative Law Judge ("ALJ") David S. Lewandowski on July 24, 2013. (Id. at 35-59). Vocational Expert ("VE") Esperanza DiStefano also testified at the hearing. (Id. at 49-57). On August 26, 2013, ALJ Lewandowski issued a decision finding Plaintiff not disabled prior to expiration of his insured status. (Id. at 18-34). The Appeals Council denied Plaintiff's request for review on April 29, 2015, rendering the ALJ's decision the final decision of the Commissioner. (Id. at 1-6). Plaintiff commenced this action on June 24, 2015. (Dkt. 1).
Plaintiff amended his alleged disability onset date to November 4, 2005, at the administrative hearing. (Tr. 38).
B. The Non-Medical Evidence
Plaintiff was 62 years old on the date of the hearing before ALJ Lewandowski. (Tr. 39). He testified that he had completed a single year of college and had previously worked for the State of New York as a plumber steam fitter. (Id. at 39-40). Plaintiff stated that he left that job in 2002 and that he then worked a couple of part-time jobs before ceasing working entirely in 2005. (Id. at 40). Plaintiff told the ALJ that he had stopped working because he was unable to climb ladders, stand for a long time, or crawl into small spaces. (Id. at 41). Plaintiff testified that he took early retirement, causing him to lose 12 and a half percent of his retirement income. (Id. ). Plaintiff testified that he worked as plumber steam fitter for 29 years. (Id. at 42).
Plaintiff testified that he had suffered from diabetes and neuropathy between November 4, 2005, and March 31, 2009. (Tr. 43). Plaintiff stated that during that time period, he would experience burning pain in his feet, and that the pain would occur several times per day and last between 20 and 30 minutes. (Id. ). Plaintiff testified that he would not have been able to perform a job that required him to stand for six hours per day because of the side effects of his diabetes medication and his neuropathy. (Id. at 44). Plaintiff stated that his medication would "knock [him] out" and that he took "at least a dozen" medications. (Id. at 45).
Plaintiff testified that he watched television, played cards, and watched his grandchildren. (Tr. 44). He also testified that he sometimes went to the park or the coffee shop, and that his children would mow his grass and he did not do any work. (Id. ).
Plaintiff testified that during the relevant time frame of November 4, 2005, to March 31, 2009, he was able to lift "30 pounds at the most but not all the time." (Tr. 46). Plaintiff also testified that he was unable to lift in part because of neuropathy in his hands. (Id. at 46-47). Plaintiff stated that he had been experiencing neuropathy in his hands and arms for "about three or four years" and that he would need treatment or "[his] fingers could close right up on [his] right hand." (Id. at 48).
C. Vocational Expert's Testimony
VE DiStefano also testified before ALJ Lewandowski. (Tr. 49-58). VE DiStefano testified that Plaintiff had previously been employed as a plumber steam fitter, which is heavy, skilled work; a plumber assistant, which is heavy, semi-skilled work; and a driver transporting medical patients, which is medium, semi-skilled work. (Id. at 50).
The ALJ presented VE DiStefano with a hypothetical question. (Tr. 50). The VE was asked to consider someone of Plaintiff's age, education, and experience who could perform light work; was limited to occasional stair climbing and balancing; could not climb ladders, ropes, or scaffolds; and should avoid hazards including heights and moving machinery. (Id. ). VE DiStefano testified that a hypothetical individual with these abilities and restrictions would not be able to perform any of Plaintiff's past work. (Id. ). The VE further testified that such a hypothetical individual would be able to perform occupations available in the national economy including file clerk, hardware clerk, and host. (Id. at 51).
The ALJ then asked the VE to consider a hypothetical individual with the abilities and restrictions listed above who could perform medium exertion work. (Tr. 51). VE DiStefano testified that such a hypothetical individual could perform as a laundry worker, a hand packer, and a kitchen helper. (Id. ).
The ALJ next asked the VE to consider someone of Plaintiff's age, education, and experience who could perform sedentary work; could sit for one hour at a time; could stand for 45 minutes; could sit for two hours and stand or walk for up to two hours during an eight hour work day; would require a break of up to 15 minutes every one to two hours; could lift 20 pounds occasionally and 10 pounds frequently; could occasionally twist, stoop, crouch, and climb stairs; could rarely (up to five percent of the time) climb ladders; should avoid concentrated exposure to extreme cold and humidity; and would be absent three days per month. (Tr. 52-53). VE DiStefano testified that such a hypothetical individual would not be able to perform any work in the national economy. (Id. at 53).
Plaintiff's attorney then questioned the VE. (Tr. 53-58). Plaintiff's attorney asked the VE for her source for the numbers of jobs available in the national economy. (Id. at 53). The VE testified that she got the numbers for the Bureau of Labor Statistics. (Id. ). Plaintiff's attorney asked if all of the available jobs were full-time, and the VE stated that some of them were part-time and that she could not break down the number of full-time versus part-time jobs on a regional basis. (Id. at 54-55). Upon further questioning, the VE testified that certain occupations were grouped together in terms of the number of jobs available because "there are other ... codes that have the same job tasks but they would be different job titles." (Id. at 56-57).
D. Summary of the Medical Evidence
The Court assumes the parties' familiarity with the medical record, which is summarized below.
Plaintiff first began treatment for diabetes in approximately 2001. (Tr. 704). On January 2, 2007, he was seen by Dr. Shahera Noukla. (Id. at 221). Plaintiff's diabetes was being treated with Metformin at that time, and his dosage had been increased the previous day. (Id. ). Plaintiff's blood sugar was 260 and his blood pressure was 139/81. (Id. ). Plaintiff reported not having taken his medication that day. (Id. ). Dr. Noukla assessed Plaintiff with diabetes mellitus type 2, continued him on Metformin, and prescribed Glucovance. (Id. ). Dr. Noukla advised Plaintiff to take his medication and to avoid beer intake, and referred him to a nutritionist. (Id. ).
Plaintiff returned to Dr. Noukla on February 2, 2007. (Tr. 220). Dr. Noukla noted that Plaintiff was noncompliant with respect to his medication and that he had not made an appointment with an endocrinologist as previously advised. (Id. ). Plaintiff reported that his blood sugar readings were between 130 and 160. (Id. ). Plaintiff agreed to take his medication "after long discussion" and Dr. Noukla "strongly advised" him to see an endocrinologist. (Id. ).
A blood test of Plaintiff taken on February 12, 2008, showed a blood glucose level of 123 mg/dl and an A1C level of 5.8 percent. (Tr. 286-88) .
The American Diabetes Association reports that for "most nonpregnant adults with diabetes" blood glucose should be between 80 and 130 mg/dl prior to a meal and less than 180 mg/dl after a meal. See http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/checking-your-blood-glucose.html (last accessed August 26, 2016).
According to the National Institute of Diabetes and Digestive and Kidney Diseases, "[t]he A1C test is a blood test that provides information about a person's average levels of blood glucose, also called blood sugar, over the past 3 months," and an A1C level of below 5.7 percent is "normal," an A1C level of 5.7 to 6.4 percent indicates prediabetes, and an A1C level of 6.5 percent or above is indicative of diabetes. See https://www.niddk.nih.gov/health-information/diabetes /diagnosis-diabetes-prediabetes/a1c-test (last accessed August 26, 2016).
Plaintiff was seen by Dr. Noukla on April 4, 2008. (Tr. 523-34). Dr. Noukla advised Plaintiff to continue with his diabetes medications and to "follow-up with diet." (Id. ). A blood test of Plaintiff taken on April 25, 2008, resulted in a blood glucose level of 127 mg/dl and an A1C level of 6.3%. (Id. at 513-14).
Plaintiff was seen by endocrinologist Dr. Karen F. Giardino on April 25, 2008. (Tr. 707). Dr. Giardino assessed Plaintiff with "non-insulin dependent diabetes mellitus —uncontrolled with increased fasting blood sugar and increased hemoglobin A1C." (Id. ). She noted that Plaintiff had not brought in any blood sugar readings for review, but reported that his fasting blood sugars ranged "from the 90s to 130s." (Id. ). Plaintiff had not consulted with the diabetic educator. (Id. ). Dr. Giardino noted that Metformin was now contraindicated for Plaintiff due to signs of early renal insufficiency. (Id. ). She recommended that Plaintiff discontinue Metformin and start taking glyburide. (Id. ). She also encouraged Plaintiff to monitor his blood sugar and to consult with a diabetic educator regarding diet management. (Id. at 707-08).A blood test of Plaintiff from October 7, 2008, showed a blood glucose level of 133 mg/dl and an A1C level of 6.0%. (Tr. 829-30). A blood test of Plaintiff from November 15, 2008, showed a blood glucose level of 135 mg/dl. (Id. at 828).
Plaintiff was seen by Dr. Noukla on October 14, 2008. (Tr. 392-94). Plaintiff's diabetes was "stable" and "managed with oral medications." (Id. at 392). Plaintiff told Dr. Noukla that he had stopped going to the endocrinologist. (Id. at 393). Plaintiff was instructed to continue on his medications. (Id. ).
Plaintiff was admitted to Millard Fillmore Suburban Hospital on January 31, 2009, due to acute renal failure. (Tr. 341). Plaintiff was treated with intravenous fluid and discharged on February 4, 2009. (Id. at 338-39). A renal ultrasound performed on March 16, 2009, was unremarkable. (Id. at 716).
Plaintiff was seen by endocrinologist Dr. Jack Cukierman on March 17, 2009. (Tr. 704-05). Dr. Cukierman noted that Plaintiff was prescribed glyburide and that he would take his medication "now and then depending on what his blood sugars are." (Id. at 704). Dr. Cukierman noted that Plaintiff's blood sugar levels were "running in the 140-150 range." (Id. ). Dr. Cukierman also noted that Plaintiff's kidney problems had "resolved." (Id. ). A blood test of Plaintiff taken on March 17, 2009, showed a blood glucose level of 146 mg/dl. (Id. at 512).
A blood test of Plaintiff taken on April 24, 2009, showed a blood glucose level of 157 mg/dl. (Tr. 824). A blood test taken on July 29, 2009, showed a blood glucose level of 161 mg/dl, and an A1C level of 7.4%. (Id. at 821). A blood test taken on December 24, 2009, showed a blood glucose level of 182 mg/dl. (Id. at 822-23). A blood test taken on December 31, 2009, showed a blood glucose level of 176 mg/dl. (Id. at 506).
Plaintiff was seen by Dr. Esfandiar Mafi on April 13, 2009. (Tr. 387-89). Plaintiff told Dr. Mafi that he was not taking any medication for his diabetes. (Id. at 387). Dr. Mafi assessed Plaintiff with uncomplicated type II diabetes and prescribed Glucotrol. (Id. at 388).
Plaintiff was seen by Dr. Mafi on April 24, 2009. (Tr. 384-86). Dr. Mafi noted that Plaintiff had recently been started on Glucotrol. (Id. at 384). Dr. Mafi adjusted Plaintiff's Glucotrol dosage, prescribed Glucophage, and counselled Plaintiff on diet and exercise. (Id. at 385).
Plaintiff was seen by Physician's Assistant ("PA") Pamela Burton on July 29, 2009. (Tr. 381-83). Plaintiff told PA Burton that he worked in the Thousand Islands area through the spring and the summer, and that he felt his medications were not working well because his blood sugar would "go no lower than 180." (Id. at 381). PA Burton assessed Plaintiff with uncontrolled, uncomplicated type II diabetes. (Id. at 382). She refilled Plaintiff's medications and "add[ed] on actos for better control of diabetes." (Id. at 382).
Plaintiff was seen by Dr. Mafi on October 20, 2009. (Tr. 378-80). Plaintiff was non-compliant with his medication at this time. (Id. at 378). Dr. Mafi noted that Plaintiff's diabetes was not well-controlled and that Dr. Mafi would "consider insulin" due to Plaintiff's chronic liver disease. (Id. at 379).
Plaintiff returned to Dr. Mafi on January 14, 2010. (Tr. 359-60). Dr. Mafi noted that Plaintiff had been prescribed insulin but had not been using it. (Id. at 359). Plaintiff told Dr. Mafi that his blood sugar was running between 127 and 190. (Id. ). He reported taking glipizide on a "sliding scale." (Id. ). Plaintiff also reported that he was working out at the gym. (Id. ).Plaintiff was seen by Dr. Mafi on March 22, 2010. (Tr. 355-58). Plaintiff was compliant with his diet and exercise. (Id. at 355). Dr. Mafi noted that on a recent lab study, Plaintiff's fasting blood sugar was elevated, but Plaintiff told Dr. Mafi that he was not actually fasting at the time of the test. (Id. at 357).
On October 24, 2012, Dr. John Pataki reviewed Plaintiff's medical record and completed a Case Analysis. (Tr. 834-35). Dr. Pataki stated that there was "insufficient evidence" regarding Plaintiff's physical limitations and that the medical evidence of record was insufficient to make a determination on Plaintiff's claim. (Id. at 834). Dr. Pataki did opine that the evidence would not support a sedentary RFC. (Id. at 835).
On October 29, 2012, Dr. Mafi completed a Residual Functional Capacity Questionnaire regarding Plaintiff. (Tr. 840-43). Dr. Mafi stated that Plaintiff had a diagnosis of "uncontrolled diabetes with neuropathy." (Id. at 840). Dr. Mafi opined that Plaintiff's symptoms would occasionally interfere with his ability to perform simple work tasks but that he was capable of low stress jobs. (Id. at 841). Dr. Mafi further opined that Plaintiff would walk two to three city blocks without rest or severe pain, that he could sit for an hour before needing to get up, that he could stand for 45 minutes at one time, that he could sit and stand/walk for about two hours in an eight hour workday, that he would need to walk for five minutes every hour, and that he needed to be able to shift positions at will. (Id. ). Dr. Mafi stated that Plaintiff would need to take unscheduled breaks every one to two hours for up to 15 minutes, and that Plaintiff would need to sit quietly during this time. (Id. at 842). According to Dr. Mafi, Plaintiff could frequently lift 10 pounds, occasionally lift 20 pounds, and rarely lift 50 pounds. (Id. ). Dr. Mafi also opined that Plaintiff could occasionally twist, stoop, crouch/squat, and climb stairs, that he could rarely climb ladders, and that he had no significant limitations in doing repetitive reaching, handling, or fingering. (Id. ). Dr. Mafi also believed that Plaintiff should avoid concentrated exposure to extreme cold and high humidity, and that he would likely be absent from work about three days per month. (Id. ). Dr. Mafi stated that the "earliest date of onset for the restrictions set forth" was "April 2009." (Id. ).
E. Determining Disability Under the Social Security Act and the ALJ's Decision
For both Social Security Insurance and Disability Insurance Benefits, the Social Security Act provides that a claimant will be deemed to be disabled "if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment 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) ; see Rembert v. Colvin , No. 13–CV–638A, 2014 WL 950141, at *6 (W.D.N.Y. Mar. 11, 2014). A disabling impairment is defined as "an impairment that results from anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostics techniques." 42 U.S.C. §§ 423(d)(3), 1382c(a)(3)(D), The burden is on the claimant to demonstrate that he is disabled within the meaning of the Act. See Draegert v. Barnhart , 311 F.3d 468, 472 (2d Cir.2002). The individual will only be declared disabled if his impairment is of such severity that he is unable to do his previous work and cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful activity. 42 U.S.C. §§ 423(d)(2)(A), 1382c(a)(3)(B).In making the disability determination, the ALJ follows a five-step sequential analysis. If the ALJ makes a determination of disability at any step, the evaluation will not continue to the next step. 20 C.F.R. § 416.920(a)(4). The five steps are as follows:
1. The Commissioner considers whether the claimant is currently engaged in substantial gainful activity.
2. If not, the Commissioner considers whether the claimant has a "severe impairment" which limits his or her mental or physical ability to do basic work activities.
3. If the claimant has a "severe impairment," the Commissioner must ask whether, based solely on medical evidence, the claimant has an impairment listed in Appendix 1 of the regulations. If the claimant has one of these enumerated impairments, the Commissioner will automatically consider him disabled, without considering vocational factors such as age, education, and work experience.
4. If the impairment is not "listed" in the regulations, the Commissioner then asks whether, despite the claimant's severe impairment, he or she has residual functional capacity to perform his or her past work.
5. If the claimant is unable to perform his or her past work, the Commissioner then determines whether there is other work which the claimant could perform. The Commissioner bears the burden of proof on this last step, while the claimant has the burden on the first four steps.
Shaw v. Chafer , 221 F.3d 126, 132 (2d Cir.2000) ; see 20 C.F.R. §§ 404.1520, 416.920.
In applying the five-step sequential evaluation in this matter, ALJ Lewandowski made the following determinations. ALJ Lewandowski determined that Plaintiff last met the insured status requirements of the Social Security Act on March 31, 2009. (Tr. 23). At step one, the ALJ found that Plaintiff was not engaged in substantial gainful activity during the relevant timeframe. (Id. ). At step two, the ALJ determined that Plaintiff had the following severe impairments: diabetes mellitus and diabetic neuropathy. (Id. ). However, the ALJ stated that Plaintiff did not meet or equal any listed impairment under step three. (Id. at 24). At step four, the ALJ evaluated Plaintiff's residual functional capacity ("RFC") and found that Plaintiff could:
perform medium work as defined in 20 CFR 404.1567(c) except he is limited to only occasional balancing and climbing stars, but no climbing ladders, ropes, or scaffolding. He also should avoid hazards including work at heights and around moving machinery.
(Id. ). The ALJ also determined at step four that Plaintiff could not perform his past relevant work. (Id. at 28). At step five, the ALJ relied on the testimony of VE DiStefano to find that Plaintiff was capable of performing work in representative occupations such as laundry worker, hand packer, and kitchen helper. (Id. at 28-29). The ALJ ultimately concluded that Plaintiff was not disabled. (Id. at 29).
III. Discussion
A. Standard of Review
This Court has jurisdiction to review the final decision of the Commissioner under 42 U.S.C. §§ 405(g) and 1383(c)(3). "In reviewing a decision of the Commissioner, a court may ‘enter, upon the pleadings and transcript of the record, a judgment affirming, modifying, or reversing the decision of the Commissioner of Social Security, with or without remanding the cause for a rehearing.’ " Rehr v. Barnhart , 431 F.Supp.2d 312, 317 (E.D.N.Y.2006) (quoting 42 U.S.C. § 405(g) ). 42 U.S.C. § 405(g) directs the Court to accept findings of fact made by the Commissioner, so long as the findings are supported by substantial evidence in the record. Substantial evidence is "more than a mere scintilla," and "relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Consol. Edison Co. v. NLRB , 305 U.S. 197, 229, 59 S.Ct. 206, 83 L.Ed. 126 (1938). "Where there is a reasonable basis for doubt whether the ALJ applied correct legal principles, application of the substantial evidence standard to uphold a finding of no disability creates an unacceptable risk that a claimant will be deprived of the right to have her disability determination made according to the correct legal principles." Johnson v. Bowen , 817 F.2d 983, 986 (2d Cir.1987).
The scope of the Court's review is limited to determining whether the Commissioner applied the appropriate legal standards in evaluating Plaintiff's claim, and whether the Commissioner's findings were supported by substantial evidence on the record. See Mongeur v. Heckler , 722 F.2d 1033, 1038 (2d Cir.1983) (stating that a reviewing Court does not examine a benefits case de novo ). If the Court finds no legal error, and that there is substantial evidence for the Commissioner's determination, the decision must be upheld, even if there is also substantial evidence for the plaintiff's position. See Perez v. Chater , 77 F.3d 41, 46 (2d Cir.1996).
Judgment on the pleadings may be granted under Rule 12(c) where the material facts are undisputed and where judgment on the merits is possible merely by considering the contents of the pleadings. See Sellers v. M.C. Floor Crafters, Inc. , 842 F.2d 639, 642 (2d Cir.1988).
B. The ALJ's Evaluation of Dr. Pataki's Opinion
Plaintiff's first argument is that the ALJ improperly evaluated the Case Analysis completed by Dr. Pataki. (Dkt. 7-1 at 10-12). Specifically, Plaintiff argues that the ALJ improperly gave "great weight" to Dr. Pataki's opinion in spite of the fact that "Dr. Pataki never actually offered an opinion." (Id. at 11).
The Court disagrees with Plaintiff's assessment of Dr. Pataki's Case Analysis. Dr. Pataki was asked to consider whether either a light or sedentary RFC was justified with respect to Plaintiff. (Tr. 834). Dr. Pataki did in fact opine that the evidence of record did not support a sedentary RFC, although his ultimate conclusion was that the medical evidence of record was insufficient to make a determination on Plaintiff's claim. (Id. ). The ALJ did not, as Plaintiff claims, "misrepresent" Dr. Pataki's opinion by noting that he had opined that a sedentary RFC was not supported by the record. However, and as discussed below, the Court does agree with Plaintiff that Dr. Pataki's Case Analysis does not actually support the ALJ's RFC finding. The sole opinion offered by Dr. Pataki with respect to Plaintiff's RFC was that a sedentary RFC was not supported by the record. Nothing in this opinion supports the medium RFC ultimately found by the ALJ. Dr. Pataki's opinion, standing alone, therefore cannot be considered substantial evidence for the ALJ's findings.
C. The ALJ's Evaluation of Dr. Mafi's Opinion and Duty to Develop the Record
Plaintiff next argues that the ALJ erred in rejecting the opinion of treating physician Dr. Mafi. (Dkt. 7-1 at 12-16). While the Court disagrees with Plaintiff, the Court does find that remand is required, for the reasons discussed below.
"Under the regulations' ‘treating physician rule,’ a treating physician's opinion will be given controlling weight if it is ‘well-supported by medically acceptable clinical and laboratory diagnostic techniques and is not inconsistent with the other substantial evidence in ... [the] record.’ " Ryan v. Astrue , 5 F.Supp.3d 493, 505 (S.D.N.Y.2014) (quoting 20 C.F.R. § 404.1527(c)(2) ). "[T]he Second Circuit has instructed that the courts should not to hesitate to remand when the Commissioner has not provided good reasons for the weight given to a treating physician[']s opinion or when the ALJ's opinion does not comprehensively set forth reasons for the weight assigned to a treating physician's opinion." Silvers v. Colvin , 67 F.Supp.3d 570, 578 (W.D.N.Y.2014) (internal quotation and citations omitted).
In this case, the ALJ gave "little weight" to Dr. Mafi's opinion because "Dr. Mafi's opinion is not material to the relevant period. ..." (Tr. 27). This is because Plaintiff was required to prove that he was disabled as of his date last insured (March 31, 2009), and Dr. Mafi affirmatively stated that the "earliest date of onset for the restrictions set forth" in his opinion was "April 2009." (Id. at 842). While Plaintiff argues that "Dr. Mafi's statement is vague," the Court agrees with the ALJ that "April 2009" is not vague and that it does not mean "March 31, 2009." It is not the role of the ALJ to rewrite medical opinions in order to make them more closely conform to the relevant timeline—Dr. Mafi said "April 2009," and the ALJ properly took him at his word. See Burgess v. Astrue , 537 F.3d 117, 129 (2d Cir.2008) (an ALJ is "not permitted to substitute his own expertise or view of the medical proof for the treating physician's opinion").
However, the Court does agree with Plaintiff that the ALJ's conclusion that Dr. Mafi's opinion was not material to the relevant time frame created a gap in the administrative record that the ALJ was required to attempt to fill. Although "[t]he claimant has the general burden of proving that he or she has a disability within the meaning of the Act ...because a hearing on disability benefits is a non-adversarial proceeding, the ALJ generally has an affirmative obligation to develop the administrative record." Burgess, 537 F.3d at 128 (internal quotation marks and brackets omitted). "[A]n ALJ may not rely, as factfinders in adversarial proceedings customarily do, on the absence of probative evidence supporting the opinions of a claimant's expert, without making an affirmative effort to fill any gaps in the record before him." Thomas v. Barnhart , No. 01 Civ. 518(GEL), 2002 WL 31433606, at *4 (S.D.N.Y. Oct. 30, 2002) (emphasis in original). "In fact, where there are deficiencies in the record, an ALJ is under an affirmative obligation to develop a claimant's medical history. ..." Rosa v. Callahan , 168 F.3d 72, 79 (2d Cir.1999). "Ultimately, ‘it is the ALJ's duty to investigate and develop the arguments both for and against the granting of benefits.’ " Amrock v. Colvin , No. 3:12–CV–55(FJS), 2014 WL 1293452, at *4 (N.D.N.Y. Mar. 31, 2014) (quoting Butts v. Barnhart , 388 F.3d 377, 386 (2d Cir.2004) ). "This affirmative obligation is present even when counsel represents the claimant." Id.
However, "the affirmative duty imposed on an ALJ to develop an administrative record fully is not without limits." Amrock , 2014 WL 1293452, at *4. The ALJ is not required to "obtain every medical file from every medical source the claimant has seen." Ubiles v. Astrue , No. 11–CV–6340 (MAT), 2012 WL 2572772, at *10 (W.D.N.Y. July 2, 2012). The ALJ is only required to "request additional evidence if the administrative record does not contain sufficient evidence to make a fair determination." Id. Indeed, "[o]n the ‘flip-side’ of this same proposition, ‘where there are no obvious gaps in the administrative record, and where the ALJ already possesses a complete medical history, the ALJ is under no obligation to seek additional information in advance of rejecting a benefits claim.’ " Hart v. Colvin , No. 12–CV–1043–JTC, 2014 WL 916747, at *7 (W.D.N.Y. Mar. 10, 2014) (quoting Petrie v. Astrue , 412 Fed.Appx. 401, 406 (2d Cir. 2011) ).
In this case, the ALJ's rejection of Dr. Mafi's opinion left a significant and obvious gap in the evidentiary record. See Gross v. Astrue , No. 12–CV–6207P, 2014 WL 1806779, at *17 (W.D.N.Y. May 7, 2014) (rejection of a treating physician's opinion created an evidentiary gap in the record that required remand). Although the Commissioner argues that there is no gap because the record contains medical records from the time period in question, an ALJ is not permitted to reach a conclusion as to a plaintiff's RFC based only on bare medical evidence. Id. at *18. "[I]t is well-settled that the ALJ cannot arbitrarily substitute his own judgment for competent medical opinion. ..." Balsamo v. Chater , 142 F.3d 75, 81 (2d Cir.1998) (internal quotation and citation omitted). Here, the only two medical opinions in the record were Dr. Pataki's opinion, which reached no conclusion regarding Plaintiff's physical capabilities, and Dr. Mafi's opinion, which the ALJ properly found was not material to the relevant time period. In other words, the record contained no competent medical opinion regarding Plaintiff's RFC during the relevant time period.
There were many avenues available to the ALJ to fill the gap in the record: he could have requested addition information from the treating physician, Dr. Mafi; he could have obtained an SSA consultative examination; and/or he could have requested an opinion from a medical expert. See Schmelzle v. Colvin , No. 6:12–CV–1159 GLS/ATB, 2013 WL 3327975, at *8 (N.D.N.Y. July 2, 2013). On remand, the Commissioner should employ whichever of these methods are appropriate to fully develop the record with respect to Plaintiff's RFC.
D. Validity of VE Testimony
Plaintiff's final argument is that VE DiStefano's testimony was not based on valid and reliable scientific methodology. (Dkt. 7-1 at 19-21). Because the Court has already determined that remand is appropriate for the reasons set forth above, it need not and does not consider this argument.
IV. CONCLUSION
For the foregoing reasons, the Commissioner's motion for judgment on the pleadings (Dkt. 12) is denied, Plaintiff's motion for judgment on the pleadings (Dkt. 7) is granted in part, and this matter is remanded for further administrative proceedings consistent with this Decision and Order.
SO ORDERED.