United States District Court, M.D. Pennsylvania
DAVID F. GARCEAU, II, Plaintiff
CAROLYN W. COLVIN, Acting Comissioner of Social Security, Defendant
William J. Nealon United States District Judge.
August 17, 2015, Plaintiff, David F. Garceau, II, filed this
instant appeal under 42 U.S.C. § 405(g) for review
of the decision of the Commissioner of the Social Security
Administration (“SSA”) denying his applications
for disability insurance benefits (“DIB”) and
supplemental security income
(“SSI”)under Titles II and XVI of the Social
Security Act, 42 U.S.C. § 1461 et seq. and 42
U.S.C. § 1381 et seq., respectively. (Doc. 1).
The parties have fully briefed the appeal. For the reasons
set forth below, the decision of the Commissioner denying
Plaintiff's applications for DIB and SSI will be
protectively filed his applications for DIB and SSI on August
12, 2013, alleging disability beginning on July 16, 2013, due
to a combination of major depression with recurring episodes,
minimal change disease, hypertension, degenerative spinal
disease, alopecia totalis, cirrhosis, migraines, bipolar
disorder, nephrotic syndrome, and acid reflux. (Tr. 23,
244). The claim was initially denied by the
Bureau of Disability Determination
(“BDD”) on January 22, 2014. (Tr. 23). On February
12, 2014, Plaintiff filed a written request for a hearing
before an administrative law judge. (Tr. 23). A hearing was
held on August 19, 2014, before administrative law judge
Barbara Artuso (“ALJ”), at which Plaintiff,
Plaintiff's mother, and an impartial vocational expert,
Mitchell A. Schmidt, (“VE”) testified. (Tr. 23).
On September 26, 2014, the ALJ issued a decision denying
Plaintiff's claims because, as will be explained in more
detail infra, Plaintiff could perform light work
with limitations. (Tr. 29).
November 19, 2014, Plaintiff filed a request for review with
the Appeals Council. (Tr. 18). On June 11, 2015, the Appeals
Council concluded that there was no basis upon which to grant
Plaintiff's request for review. (Tr. 1-3). Thus, the
ALJ's decision stood as the final decision of the
filed the instant complaint on August 17, 2015. (Doc. 1). On
October 2, 2015, Defendant filed an answer and transcript
from the SSA proceedings. (Docs. 6 and 7). Plaintiff filed a
brief in support of his complaint on October 26, 2015. (Doc.
8). Defendant filed a brief in opposition on November 30,
2015. (Doc. 9). On December 11, 2015, the action was
dismissed without prejudice subject to renewal within thirty
(30) days upon Plaintiff presenting evidence that he did not
receive the Appeals Council's notice within the five (5)
day presumption period in order for his claim to be
administratively exhausted. (Doc. 10). On March 3, 2016, in
compliance with the previous Order and upon proof that
Plaintiff did not receive the notice within the presumption
period, this Court reinstated the action and deemed
Plaintiff's appeal to be timely filed. (Doc. 12).
Plaintiff was also granted thirty (30) days to file a reply
brief from the date of reinstatement, but did not do so.
was born in the United States on April 8, 1980, and at all
times relevant to this matter was considered a “younger
individual.” (Tr. 228). Plaintiff completed two (2)
years of college, and can communicate in English. (Tr. 243,
245). His employment records indicate that he previously
worked as a laborer, loan counselor, maintenance worker,
market researcher, and a utilization review coordinator. (Tr.
document entitled “Function Report - Adult” filed
with the SSA on December 9, 2013, Plaintiff indicated that he
lived in a house with his family. (Tr. 288). From the time he
woke up until he went to bed, Plaintiff showered, watched
television, rested, ate his meals, and went to any scheduled
appointments. (Tr. 287). Plaintiff was able to take care of
his personal needs, prepare his own meals daily for fifteen
(15) minutes at a time, do the laundry, vacuum, take out the
trash, grocery shop once a month for about an hour, and drive
a car. (Tr. 284-287). When asked to check items which his
“illnesses, injuries, or conditions affect, ”
Plaintiff did not check reaching, kneeling, talking,
hearing, stair climbing, seeing, memory, understanding,
following instructions, or using hands. (Tr. 283). He was
able to walk about fifty (50) yards before needing to stop
and rest for about three (3) to five (5) minutes. (Tr. 283).
his concentration and memory, Plaintiff did not need special
reminders to go places, to take care of his personal needs,
or to take his medicine. (Tr. 284, 286). He could count
change, handle a savings account, and use a checkbook, but
did not pay bills because he could not afford to pay all of
them. (Tr. 285). He did not finish what he started, could pay
attention for a half hour, followed written and spoken
instructions “good, ” and handled stress and
changes in routine poorly. (Tr. 282-283).
Plaintiff went outside three (3) times a day, was able to
attend his mental health appointment and go grocery shopping
on a daily basis unattended, and spent time with others both
in person and on the phone. (Tr. 284-285). His hobbies and
interests included watching television and “tie
flys” on a daily basis. (Tr. 284). He reported that he
had no problems getting along with others. (Tr. 281-282).
Supplemental Questionnaire regarding pain, Plaintiff
indicated that his pain began in 2001 after heavy lifting
resulted in a herniated disc, and that it was stabbing and
sharp in nature. (Tr. 277, 291). He stated that his pain
changed depending on activity. (Tr. 277, 291). The location
of his pain was in his lumbar region down his legs. (Tr. 277,
291). He avoided all physical activities because they
increased his pain. (Tr. 277). His pain was worse in the
morning, occurred daily, and lasted for a few hours to days.
(Tr. 277, 291). Ibuprofen did not relieve his pain, and
Plaintiff had tried physical therapy, hot showers, a TENS
unit, and cortisone shots to relieve his pain. (Tr. 279,
Supplemental Questionnaire for fatigue, Plaintiff noted that
his fatigue began in 2006 due to depression, bipolar disorder
medication, and mitral valve regurgitation, that it was worse
in the afternoon and evenings, that it occurred daily, that
it lasted a few hours to days, and that it was relieved by
sleep. (Tr. 278, 292).
hearing, Plaintiff indicated that he could not work due to a
combination of depression as a result of alopecia, a ruptured
disc in his back, hypertension, migraines, and minimal change
disease for nephrotic syndrome, . (Tr. 54-55, 62).
medications, Plaintiff testified that he was taking Soboxone
for drug addiction issues, and that it was helpful. (Tr. 56).
He was also taking Zyprexa, Effexor, Lamictal, a tapered dose
of Prednisone, and Metoprolol. (Tr. 56). Some side effects
from these medications noted by Plaintiff included
drowsiness, fatigue, and issues with focus and concentration.
(Tr. 57). He also indicated that he saw a therapist every two
(2) weeks for his mental health and drug addiction issues.
his mental health impairments, Plaintiff testified that he
had Bipolar Disorder, which caused him to isolate himself
during “those really bad depressive times.” (Tr.
60). He stated, “Again I put a lot of emphasis on what
other people are thinking about me. It makes it hard and - -
with coworkers or dealing with the public.” (Tr.
60-61). He stated that his memory, concentration, focus, and
ability to get along with others were affected by his mental
health problems. (Tr. 63).
physical impairments, Plaintiff testified that he experienced
back pain, elbow pain, and patellofemoral pain. (Tr. 61). His
back pain made him avoid lifting because he wanted to avoid
narcotics, as he had addiction problem with them. (Tr. 63).
Sitting also exacerbated his back pain. (Tr. 63). He stated
that he could lift no more than twenty (20) pounds. (Tr. 63).
He stated that he had experienced about four (4) or five (5)
relapses of nephrotic syndrome that required large amounts of
steroids. (Tr. 62).
activities of daily living, Plaintiff testified that he was
able to take care of his personal needs, prepared one (1)
meal a day, watched television, attended any scheduled
doctor's appointments, did his own laundry, would
sometimes cook for his family, would vacuum when he was
capable, shopped for groceries, and took care of his dog.
medical records for the relevant time period of
Plaintiff's alleged onset date of July 16, 2013, through
the date of the ALJ's decision of September 26, 2014,
will be reviewed and summarized.
October 6, 2013, Plaintiff presented to Mount Nittany
Hospital due to complaints of fatigue, shortness of breath,
fever, nausea, and an occasional cough that had been
occurring for the past few months. (Tr. 694, 699). Cardiac
testing revealed Plaintiff had acute infectious endocarditis
and severe mitral valve regurgitation due to a history of
intravenous heroin abuse. (Tr. 688, 694, 699-701, 730-743,
775). For treatment, Plaintiff received intravenous
antibiotics for six (6) weeks. (Tr. 717, 720, 722). Plaintiff
was discharged on October 15, 2013 with diagnoses of acute
endocarditis, acute systolic heart failure, severe mitral
valve regurgitation, IV drug abuse, hypertension, and
psoriasis. (Tr. 720, 797, 803).
was admitted to Hershey Medical Center from October 16, 2013
to October 25, 2013 for the aforementioned diagnoses of his
heart after his symptoms returned several hours after
discharge from Mount Nittany Hospital. (Tr. 817-818). He was
given intravenous antibiotic treatment for strep viridans
mitral valve endocarditis. (Tr. 818).
January 2, 2014, Plaintiff has a pre-surgical appointment
with Jason Fragin, D.O., to discuss mitral valve repair
options. (Tr. 1098).
March 11, 2014, Plaintiff underwent a mitral valve repair
performed by Behzad Soleimani, M.D. (Tr. 1124).
March 31, 2014, at a post-surgical follow-up appointment, Dr.
Soleimani noted that a Transesophageal Echocardiogram Report
(“TEE”) study revealed no mitral regurgitation or
stenosis, and that the valve repair was a success. (Tr. 1096,
Knee, Hip, and Back Impairments
October 2, 2013, Plaintiff underwent an x-ray of his left
knee that showed no abnormalities. (Tr. 765). He also
underwent an x-ray of his lumbar spine due to a history of
spondylosis, and this x-ray revealed mild levoscoliosis. (Tr.
766). An x-ray of his right hip was negative for
abnormalities. (Tr. 767).
March 23, 2013, Thomas E. Covaleski, M.D., examined Plaintiff
at the Mount Nittany Medical Center, when he was admitted for
intoxication, and noted that his past medical history
included “Nephrotic syndrome as a child which has
resolved.” (Tr. 648). On November 15, 2013, Dr. Dranov
noted that Plaintiff had childhood nephrotic syndrome, but
that a biopsy demonstrated it to be a “nil”
disease. (Tr. 857, 867). The renal biopsy showed no
pathologic diagnosis, and Plaintiff's renal function had
remained stable. (Tr. 425). Dr. Dranov noted on March 5,
2013, that Plaintiff did not have “any sense that his
nephrotic syndrome has recurred.” (Tr. 416). In
December 2013, Dr. Pote noted that Plaintiff had nephrotic
syndrome that was in remission. (Tr. 857).
Mental Health Impairments
October 2013 forward, Plaintiff had an appointment once a
month with Timothy Derstine, M.D. for depression, drug
addiction, and bipolar disorder. (Tr. 837). The treatment
notes from these visits are largely illegible. (Tr. 837-842).
March 28, 2013, Dr. Derstine noted that Plaintiff had
previously been in three (3) to four (4) different drug
treatment programs, had been psychiatrically hospitalized
three (3) or four (4) times in the past, and that he had
relapsed one month after a recent inpatient rehabilitation
stay in Roxbury a year earlier. (Tr. 847). Dr. Derstine noted
that Plaintiff reported actively doctor-seeking, hospital
surfing, and lying about his medical conditions in order to
obtain controlled prescriptions. (Tr. 847).
April 23, 2013, it was noted that Plaintiff was
“‘struggling not to use, '” that he was
using more days out of the week progressively and using more
drugs when he would use, that he was using opioids and
heroin, that he binged for four (4) to five (5) days at a
time, that he intermittently started to use crack cocaine,
and that, despite his use, he had been going to work. (Tr.
843). His physical examination revealed a goal-directed
thought process, good eye contact, a constricted and blunt
affect, and impaired insight. (Tr. 843). His diagnoses
included Bipolar Disorder and Polysubstance Abuse. (Tr. 843).
It was recommended that he should attend an intensive
outpatient program, but he was not willing to do so. (Tr.
September 23, 2013, Dr. Derstine reported that Plaintiff was
still using heroin and drinking. (Tr. 830). Plaintiff was