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Thoma v. Colvin

United States District Court, W.D. Pennsylvania

December 2, 2014

CAROLYN W. COLVIN, [1] Acting Commissioner of Social Security Administration, Defendant

For WILLIAM SAMUEL THOMA, SR., Plaintiff: Christine M. Nebel, LEAD ATTORNEY, Butler, PA.

For CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant: Christy Wiegand, LEAD ATTORNEY, United States Attorney's Office (PGH), Pittsburgh, PA.


Re: ECF Nos. 12, 14




Plaintiff, William Samuel Thoma, Sr. (" Plaintiff"), brought this action pursuant to 42 U.S.C. § 405(g), seeking review of the Commissioner of Social Security's final decision denying his claim for disability insurance benefits (" DIB") and supplemental security income (" SSI") under Titles II and XVI of the Social Security Act (" the Act"), 42 U.S.C. § 401-433, 1381-1383f. Pending before the Court are the parties' cross-motions for summary judgment. (ECF Nos. 12, 14). It is respectfully recommended that the Motion for Summary Judgment filed by Plaintiff (ECF. No. 12) be denied and the Motion for Summary Judgment filed by Defendant (ECF No. 14) be granted.


A. Procedural History

Plaintiff protectively filed his application for DIB on April 1, 2011, and his application for SSI on November 11, 2011, alleging disability since October 25, 2011, due to hemochromatosis, irregular heartbeat, high blood pressure, anxiety, dizziness, fainting spellings, acid reflux and bleeding ulcers. (R. 181-198). Plaintiff's applications for benefits were denied by Pennsylvania Bureau of Disability Determination on May 21, 2012; thereafter, Plaintiff requested a hearing before an administrative law judge. (R. 5-6, 111-20). On April 25, 2013, Plaintiff, represented by counsel, and Karen S. Krull, an impartial vocational expert (" VE"), testified at the hearing before Administrative Law Judge James J. Pileggi (" the ALJ"). (R. 31-71).

On June 7, 2013, the ALJ issued his decision finding that Plaintiff could perform limited unskilled sedentary work existing in significant numbers in the national economy, and therefore, Plaintiff was not disabled under the Act. (R. 23). The Appeals Council denied Plaintiff's request for review. (R. 1-4). On November 25, 2013, Plaintiff initiated this action seeking judicial review of the ALJ decision. (R. 1-3).

B. Factual Background

1. Medical History

Plaintiff alleged disability stemming from hemochromatosis, irregular heartbeat, high blood pressure, anxiety, dizziness, fainting spellings, acid reflux and bleeding ulcers with an alleged onset date of October 25, 2011. Plaintiff's relevant treatment records reveal that none of the cited impairments are so severe as to preclude substantial gainful employment.

Over six months prior to Plaintiff's alleged disability onset date, Plaintiff visited Butler Memorial Hospital with symptoms related to pancreatitis. (R. 436). Treatment notes indicate that Plaintiff suffered from ongoing alcohol abuse and dependency. (R. 436). Plaintiff underwent a psychiatric consultation regarding his alcoholism and admitted that, while he was not currently being treated for his alcoholism, he previously attended rehabilitation and underwent detoxification. (R. 436). Plaintiff drank eight to ten drinks each day, which he did not consider " that much." (R. 436). Plaintiff was not interested in seeking rehabilitative treatment. (R. 436-37). During his examination, Plaintiff's alcohol level measured at .366. (R. 437). He appeared inattentive and explained that he suffers from hallucinations. (R. 437). However, Plaintiff did not report any major mood symptoms. (R. 437).

A week later, on March 22, 2011, Plaintiff again sought treatment at Butler Memorial Hospital and was admitted with acute GI symptoms. (R. 434). During his hospitalization, Plaintiff underwent detoxification for alcohol and Ativan, and appeared disoriented and confused. (R. 434). On March 24, 2011, against medical advice, Plaintiff left the hospital. (R. 434). He refused to fill out discharge paperwork and his detoxification attempt was deemed unsuccessful. (R. 434).

On April, 18, 2011, Plaintiff followed-up with his general care physician, John Rocchi, M.D. (R. 278). Plaintiff reported that he had stopped drinking alcohol and had not experienced any withdrawal symptoms. (R. 278). He stated that his Ativan prescription " worked well" and he only took one pill each day. (R. 278). Dr. Rocchi diagnosed Plaintiff with alcohol dependency, epigastric pain and hypertension. (R. 279). During Plaintiff's June 23, 2011, appointment, Plaintiff complained of feeling jittery and anxious. (R. 277). Dr. Rocchi prescribed Zoloft and Ativan to treat anxiety and ordered Plaintiff to follow-up in a month. (R. 277). During a July 21, 2011, appointment, Dr. Rocchi continued Plaintiff's Zoloft and Ativan prescriptions. (R. 267, 269).

Plaintiff was hospitalized at Butler Memorial Hospital on October 14, 2011, after he experienced dizziness and lightheadedness and was diagnosed with atrial fibrillation. (R. 416). During his hospitalization, his doctors questioned whether Plaintiff had quit drinking, although he reported doing so. (R. 421). Plaintiff acted anxiously and appeared as if he was experiencing withdrawal. (R. 422). On October 18, 2011, upon discharge from the hospital, Plaintiff followed-up with Dr. Rocchi who continued to prescribe Ativan and Zoloft. (R. 271, 273).

On November 16, 2011, Plaintiff again visited Dr. Rocchi and complained of stomach pains, leg numbness and back and leg pain. (R. 351). Plaintiff had not experienced any recent chest pains, but became sweaty during the night. (R. 351). Plaintiff underwent a spine lumbosacral examination which revealed wedge deformities and mild disc space narrowing. (R. 355). On November 23, 2011, Plaintiff had an MRI performed of his lumbar spine demonstrating mild disc space narrowing, but no evidence of focal disc protrusion or stenosis was identified. (R. 507).

Plaintiff returned to Dr. Rocchi for a follow-up appointment on January 24, 2012. Plaintiff reported that he had sought drug and alcohol addiction treatment and had been hospitalized from January 3, 2012, through January 8, 2012. (R. 534). During his inpatient hospitalization, Plaintiff was also treated for depression and prescribed an antidepressant. However, Plaintiff noted he was no longer taking the medication. (R. 534). During his appointment, Plaintiff complained of low back pain which radiated into his legs and right elbow and shoulder pain. (R. 534). Plaintiff could lift his arms over his head, but explained that he had difficulty bending, squatting, and sitting or standing for prolonged periods of time. (R. 534).

On January 25, 2012, Dr. Rocchi completed a Department of Public Welfare Employability Assessment and after briefly listing Plaintiff's complaints of leg pain and numbness, Dr. Rocchi checked a box indicating that Plaintiff was temporarily disabled for a period of one year. Dr. Rocchi or his staff listed diagnoses of depression, atrial fibrillation and low back pain, but did not provide any information regarding the basis for his opinion, such as an examination, review of Plaintiff's clinical history or ongoing treatment. (R. 673). Dr. Rocchi also indicated that Plaintiff required Zoloft to treat his depression so that he could work in some capacity.

Plaintiff sought pain management from Mark R. LoDico M.D., on February 14, 2012, and complained of pain all over. (R. 657). Plaintiff rated the pain as an eight out of ten and reported that heat treatment, Vicodin, OxyContin, and Tylenol provided partial relief. (R. 657). Plaintiff arrived at the appointment unaccompanied and could walk and squat with minimal difficulty. (R. 658). He had full muscle strength and range of motion in his extremities. (R. 658). Following referral by Dr. Rocchi, Plaintiff saw Devashis Mitra, M.D., on February 22, 2012, for Plaintiff's joint and low back pain. (R. 526). Dr. Mitra's examination revealed that Plaintiff had no inflammation in his upper and lower extremities, but experienced some tenderness in his spine and crepitus movement in both knees. (R. 527). Plaintiff's knee x-rays were unremarkable and his sacroiliac joints, wrist and hand x-rays revealed normal findings. (R. 559-65). Plaintiff's right foot showed signs of early osteoarthritis and his left foot showed signs of possible early gouty arthritis. (R. 566-67).

On February 23, 2012, Plaintiff returned to Dr. LoDico with continued complaints of pain and Dr. LoDico administered a lumbar epidural steroid injection. (R. 654-55). On March 16, 2012, Plaintiff underwent additional steroid injections. (R. 649). Plaintiff reported that the steroid injections relieved his pain for eight days. (R. 626).

On March 29, 2012, Plaintiff saw Robert Waltrip, M.D. at Tri-Rivers Surgical Associates for an evaluation of his right shoulder. (R. 592). Dr. Waltrip noted no gross abnormality or tenderness and indicated that Plaintiff maintained good motion and strength. (R. 592). Overall, Dr. Waltrip opined that Plaintiff likely suffered bursitis in his shoulder, but would not prescribe pain medication. (R. 592). Instead, Dr. Waltrip recommended steroid injections, home exercise and over-the-counter pain medication. (R. 592).

On April 26, 2012, during a pain management appointment, Plaintiff complained of lower back pain in his right side and rated it as a ten out of ten. (R. 643). Dr. LoDico again administered steroid injections. (R. 644). On May 7, 2012, Plaintiff returned with continued complaints of back pain. (R. 641). Plaintiff attended the appointment unaccompanied and could rise from a seated position without assistance. (R. 642). Due to Plaintiff's history of addiction, Dr. LoDico noted that Plaintiff was not a candidate for narcotic therapy to relieve his pain. (R. 642). During the appointment, Plaintiff smelled of alcohol. (R. 642).

In July 2012, Plaintiff fell while in the shower. (R. 55-57). His accident resulted in an open wound, pain and numbness in his right hand. (R. 727). On August 2, 2012, Plaintiff saw Dr. Rocchi and reported that he had fallen in the bathroom. (R. 727). Plaintiff next saw Dr. Rocchi five months later, on January 31, 2013. Plaintiff complained of stomach pain lasting a month. (R. 723). Plaintiff indicated that he felt depressed, continued to drink alcohol, and had not been able to work due to his hand. (R. 723). Dr. Rocchi prescribed Zoloft for Plaintiff. (R. 725).

In February 2013, Plaintiff underwent surgery for his right wrist injury that stemmed from his previous fall in the bathroom. (R. 732). His surgeon, H. James Pfaeffle, M.D., recommended that Plaintiff attend therapy for active range of motion and avoid gripping for six to eight weeks. (R. 732). Post-surgery, Dr. Pfaeffle found that, as of March 20, 2013, Plaintiff's wounds healed, sensation returned to his finger, and he could pinch his thumb and index finger together. (R. 735).

On March 4, 2013, Plaintiff had an appointment with Dr. Rocchi. (R. 718). Plaintiff provided an update as to his hand surgery. He also conveyed that he felt depressed because of his recent divorce. (R. 718). Plaintiff thought that the Zoloft helped his depression and explained that he sought out a counselor, but had not yet scheduled an appointment. (R. 718).

Dr. Rocchi referred Plaintiff to James A. Craig Jr., D.O., at Tri-Rivers Surgical Associates for a consultation regarding his back pain. On March 18, 2013, and Plaintiff reported to Dr. Craig that his previous steroid injections and Vicodin relieved his pain. (R. 737). Dr. Craig took over Plaintiff's pain management and had ...

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