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Garceau v. Colvin

United States District Court, M.D. Pennsylvania

March 23, 2017

CAROLYN W. COLVIN, Acting Comissioner of Social Security, Defendant


          William J. Nealon United States District Judge.

         On August 17, 2015, Plaintiff, David F. Garceau, II, filed this instant appeal[1] 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”)[2]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 affirmed.


         Plaintiff protectively filed[3] 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).[4] The claim was initially denied by the Bureau of Disability Determination (“BDD”)[5] 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).

         On 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 Commissioner.

         Plaintiff 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. (Doc. 12).

         Plaintiff was born in the United States on April 8, 1980, and at all times relevant to this matter was considered a “younger individual.”[6] (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. 232).

         In a 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).

         Regarding 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).

         Socially, 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).

         In a 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, 293).

         In a 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).

         At his 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).

         Regarding 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. (Tr. 57).

         Regarding 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).

         Regarding 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).

         Regarding 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. (Tr. 63-65).


         The 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.

         A. Physical Impairments

         1. Endocarditis

         On 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).

         Plaintiff 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).

         On January 2, 2014, Plaintiff has a pre-surgical appointment with Jason Fragin, D.O., to discuss mitral valve repair options. (Tr. 1098).

         On March 11, 2014, Plaintiff underwent a mitral valve repair performed by Behzad Soleimani, M.D. (Tr. 1124).

         On 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, 1116).

         2. Knee, Hip, and Back Impairments

         On 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).

         3. Nephrotic Syndrome

         On 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).

         B. Mental Health Impairments

         From 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).

         On 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).

         On 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. 843).

         On September 23, 2013, Dr. Derstine reported that Plaintiff was still using heroin and drinking. (Tr. 830). Plaintiff was ...

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