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Messina v. Colvin

United States District Court, D. Connecticut

February 6, 2017

JOSEPH J. MESSINA, Plaintiff,
v.
CAROLYN W. COLVIN, COMMISSIONER OF SOCIAL SECURITY, Defendant.

          RULING ON THE PLAINTIFF'S MOTION TO REVERSE AND THE DEFENDANT'S MOTION TO AFFIRM THE DECISION OF THE COMMISSIONER

          Vanessa L. Bryant, United States District Judge

         This is an administrative appeal following the denial of the Plaintiff, Joseph Messina's, application for disability insurance benefits (“DIB”).[1] It is brought pursuant to 42 U.S.C. §§ 405(g).

         Joseph Messina (“Plaintiff” or “Messina”) has moved for an order reversing the decision of the Commissioner of the Social Security Administration (“Commissioner”), or remanding the case for rehearing. [Dkt. No. 15.] The Commissioner, in turn, has moved for an order affirming the decision. [Dkt. No. 16.]

         For the following reasons, Messina's Motion for an Order Reversing or Remanding the Commissioner's Decision [Dkt. No. 15] is DENIED, and the Commissioner's Motion to Affirm that Decision [Dkt. No. 16] is GRANTED.

         I. Factual Background

         The following facts are taken from the parties' Joint Stipulation of Facts (“Joint Stipulation”) [Dkt. No. 21] unless otherwise indicated.

         a. Plaintiff's Background

         Messina was born in 1968. [Dkt. No. 21 at 43.] He graduated from college with a degree in accounting. Id. He worked as an accountant for four years and stopped because the “very professional environment . . . wasn't the environment [he] felt comfortable in.” [Dkt. No. 7-3 at 32-33.] Messina then opened and ran a restaurant from 2006 to May 10, 2008, the alleged onset date of his disability. [Dkt. No. 21 at 43.] He was last insured on December 31, 2008.[2] Id. On July 30, 2012, Messina applied for a Period of Disability and Disability Insurance Benefits. [Dkt. No. 7-6 at 157]. On September 12, 2012, a disability adjudicator in the Social Security Administration denied his initial request for disability benefits and thereafter denied his request for reconsideration. [Dkt. No. 7-5 at 69-73.]

         On May 6, 2014, Messina appeared (with counsel) for a hearing before an Administrative Law Judge (“ALJ”). [Dkt. No. 7-3 at 27.] On June 9, 2014, the ALJ issued a decision denying benefits. Id. at 7. On September 30, 2015, the appeals council denied Messina's request for review of that decision thereby making the ALJ's decision the final decision of the Commissioner. Id. at 1. This appeal followed.

         b. Plaintiff's Medical History

         i. Messina's automobile accidents and early medical treatment

         Messina was involved in an automobile accident on May 10, 2008, [3] and was transported via emergency helicopter to Hartford Hospital. [Dkt. No. 21 at 1; Dkt. No. 7-8 at 548.] The emergency trauma team diagnosed Messina with left radial ulnar dislocation, rib fractures, pulmonary contusion, possible splenic kidney laceration, fixed fracture, left elbow dislocation, and thoracic spine tenderness. Id. The trauma team also found Messina was intoxicated. Id.

         On May 12, 2008, Dr. Evan Fox, a hospital psychiatrist, evaluated Messina's mental health. [Id. at 3; Dkt. No. 7-8 at 556.] Messina told Dr. Fox he experienced mood fluctuations and depression. Id. Messina denied suicidal ideation and stated his anxiety was relieved with medication prescribed by Dr. Timothy Fignar, his primary care physician, as well as marijuana and alcohol. Id. Dr. Fox noted Messina seemed agitated and angry, but that his thought processes were logical and coherent. Id.

         Messina was discharged on May 13, 2008 with prescriptions for pain medications, muscle relaxers and antidepressants. [Dkt. No. 21 at 3; Dkt. No. 7-8 at 571-575.]

         Messina met with Dr. Fignar on May 16 and again on May 30, 2008. [Dkt. No. 7-8 at 363, 368.] Dr. Fignar gave Messina a mental health screening questionnaire which suggested a likely bipolar diagnosis and suggested Messina see a psychiatrist. Id. at 363. Dr. Fignar also offered Messina a handout discussing depression, instructed him to exercise and avoid depressants including alcohol, and adjusted Messina's anxiety medication. Id.

         An orthopedist, Dr. Robert Belniak, examined Messina on June 3, 2008. [Dkt. No. 21 at 5; Dkt. No. 7-8 at 282.] Dr. Belniak found Messina experienced a 20 degree extension loss in his elbow, some chronic low back pain with radiation to the lower leg, and some impingement symptoms in his left shoulder, although an X ray of Messina's shoulder was normal. [Dkt. No. 7-8 at 282.] Dr. Belniak prescribed an anti-inflammatory and physical therapy. Id. Messina benefitted from physical therapy, and when he saw Dr. Belniak on July 1, 2008, his left shoulder and left elbow had improved. Id. at 281. However, Messina's lower back pain continued. Id. Dr. Belniak referred him to a spine specialist and prescribed him Vicodin. Id.

         Also on July 1, 2008, Messina was in a motorcycle accident. [Dkt. No. 7-8 at 368.] He was admitted to New Britain Hospital, where x-rays revealed several fractures, although the physician could not fully discern which were caused by his May 2008 accident rather than his July 2008 accident. Id. Messina complained of pain, swelling, redness, numbness, weakness, and difficulty breathing. Id. Messina was prescribed an anti-inflammatory and a pain reliever. Id. After his July 2008 accident, Messina saw a number of physicians for shoulder pain, mental health, and lower back pain. Messina's medical history pertaining to each condition is discussed in turn below.

         ii. Messina's Shoulder Pain

         On July 25, 2008, an MRI revealed a tear of the anterior superior glenoid labrum in his right shoulder. [Dkt. No. 21 at 10; Dkt. No. 7-8 at 266.] On October 22, 2008, Dr. Belniak performed an arthroscopic labral reconstruction operation to repair the tear. [Dkt. No. 21 at 13; Dkt. No. 7-8 at 289-90.] One week after his surgery, on October 28, Messina reported “the previous pain he was having [in his right shoulder] is gone.” [Dkt. No. 7-8 at 277.] Dr. Belniak noted Messina was “able to move the shoulder without much discomfort” and instructed Messina to practice “gentle range of motion exercises.” Id.

         On November 18, 2008, Dr. Belniak found Messina had “good early range of motion of his shoulder with minimal pain under shoulder level.” [Dkt. No. 7-8 at 276.] Dr. Belniak prescribed physical therapy and restricted Messina from heavy lifting. Id.

         On December 16, 2008, Dr. Belniak found Messina had full overhead range of motion and would “gradually resume his normal activities.” [Dkt. No. 7-8 at 275.] Messina reported his “pain has largely gone away.” Id.

         iii. Messina's Mental Health

         On August 1, 2008, Messina returned to Dr. Fignar for continued mental health treatment. [Dkt. No. 7-8 at 370.] Messina reported his “feelings of being up and down [were] mostly resolved with treatment” and he was “finding enjoyment in life in general and [had] no further disturbances in sleep or appetite [and] denie[d] suicidal ideation.” Id. Dr. Fignar instructed Messina to continue exercising and avoiding “alcohol and other depressing[4] drugs, ” and made no adjustments to his mental health medications. Id.

         Through the remainder of the relevant time period, Messina routinely reported no depression or only mild symptoms. [See, e.g., Dkt. No. 7-8 at 372 (September 23, 2008 report to Dr. Fignar that Messina's antipsychotic medication was working well); id. at 231 (December 1, 2008 medical notes from Dr. Patel, Messina's pain management specialist, recording Messina's depression level at two out of ten); id. at 376 (December 16, 2008, medical notes from Dr. Fignar indicating Messina's “excellent response” to his antipsychotic medication).]

         iv. Messina's Spine Condition

         On July 16, 2008, Messina saw an interventional pain management physician, Dr. Roshni N. Patel, who found Messina had radiculopathy affecting his left leg, limited mobility, mild tenderness and spasms in his lower back. [Dkt. No. 21 at 7; Dkt. No. 7-8 at 253-58.] Dr. Patel advised Messina to attend physical therapy for sciatica, continue taking pain medication prescribed by Dr. Fignar, and use a local anesthetic targeting his rib fracture pain. Id. Dr. Patel's treatment improved Messina's sciatica. [Dkt. No. 7-8 at 280.] By July 29, Messina experienced intermittent sharp pains that were worse when bending, but overall experienced a “good benefit” from physical therapy. Id. at 251.

         On July 18, 2008, Messina met with Dr. Robert Pepperman, a physical medicine and rehabilitation specialist. [Dkt. No. 21 at 8; Dkt. No. 7-8 at 291-92.] Dr. Pepperman conducted an electrodiagnostic study of Messina's lower limbs, which revealed normal results inconsistent with peripheral neuropathy or lumbar radiculopathy or myopathy. [Dkt. No. 7-8 at 292.] Dr. Pepperman denied Messina's request for a prescription for Percocet, finding it medically unnecessary. Id.

         On July 29, 2008, Dr. Patel examined Messina and found no limitation in his range of motion due to radioculopathy, no motor weakness or sensory loss, the ability to raise his right leg more than 60 degrees and his left leg 40 degrees. [Dkt. No. 21 at 11; Dkt. No. 7-8 at 252.] Dr. Patel prescribed additional numbing patches to treat his chest pain. Id.

         On October 30, 2008, Dr. Patel examined Messina and reported limited range of motion due to radiculopathy, moderate tenderness, and mild sensory loss. [Dkt. No. 7-8 at 245.] On November 4, 2008, Dr. Patel treated Messina's sciatica with epidural steroid injections. Id. at 244, 246.

         On November 3, 2008, Messina had an MRI of his lumbar spine which revealed normal alignment, degenerative disc disease, and degenerative facet hypertrophy (degeneration of joints along the back of the spine). [Dkt. No. 21 at 16; Dkt. No. 7-8 at 228-30.]

         On November 12, 2008, one week after his epidural steroid injections, Messina reported a pain level of five, decreased from seven. [Dkt. No. 7-8 at 236.] Messina reported sciatic pain in his left buttock and left leg occurring for one to two hours every morning. Id. Messina stated his pain was managed with Vicodin. Id. Dr. Patel examined Messina and found a limited range of motion due to his radiculopathy, mild tenderness and spasms, and improved ability to raise his leg. Id. at 237. Dr. Patel prescribed physical therapy and an anti-inflammatory. Id. On November 18, 2008, Dr. Patel administered additional epidural steroid injections. [Dkt. No. 21 at 20; Dkt. No. 7-8 at 235.]

         On December 1, 2008, Dr. Patel recorded Messina's sciatic pain level between eight and ten out of ten. [Dkt. No. 21 at 21; Dkt. No. 7-8 at 231.] Dr. Patel noted Messina's continued limited range of motion due to radiculopathy, moderate tenderness and spasms, mild sensory loss, and ability to raise his left leg 40 degrees. Id. at 232. Overall, Dr. Patel found Messina's performance was consistent with normal activity with effort and some signs or symptoms of disease. Id. at 233. Dr. Patel referred Messina to Dr. William H. Druckemiller, a spine and neurological surgery specialist. Id.

         On December 12, 2008, Dr. Druckemiller evaluated Messina and noted he had symptoms consistent with “radiculopathy that has partially cleared.” [Dkt. No. 261.] He instructed Messina to start a back exercise program and noted that if Messina failed to improve, “surgery might become a consideration.” Id. at 262.

         v. Messina's medical history after the relevant time period

         Dr. Fignar continued prescribing Messina pain medications, muscle relaxants, and anti-inflammatories after December 31, 2008, the close of the relevant time period. [Dkt. No. 21 at 27-28; see also, e.g., Dkt. No. 7-8 at 396 (pain medication prescribed for left leg and back pain February 2009); 408 (muscle relaxer prescribed for left leg and back pain August 2009); 415 (pain medication prescribed for back and shoulder pain December 2009); 442 (pain medication prescribed for back pain February 2010); 451 (pain medication prescribed for back pain May 2010); 506 (pain medication prescribed for back pain January 2011); 544 (pain medication prescribed for back pain July 2012); 647 (pain medication prescribed for “chronic pain” May 2013).] Dr. Fignar prescribed Messina pain medication sixty-seven times in the five and two-half year period between January 2009 and March 2014. [Dkt. No. 21 at 27-28; Dkt. No. 7-8 at 391-99; 401-02, 405, 407, 409-10, 415, 440, 442, 444, 447, 450-51, 453, 455-57, 461-62, 506, 508-09, 511-13, 515, 517, 520-21, 523, 525, 527, 531, 534-36, 542-43, 547, 635, 637, 640, 643-44, 646-47, 650, 652-54, 676-78, 680-82.]

         On February 4, 2010, Messina complained of persistent knee pain “since his accident a year and a half ago, which has gotten much worse on the right side recently.” [Dkt. No. 7-8 at 274.] On March 1, 2010, Dr. Belniak operated on Messina's right knee, repairing a tear of the lateral meniscus. Id. at 287. On March 9, 2010, Messina reported his right knee pain had subsided. Id. at 272. A postoperative exam revealed Messina's range of motion was good, neurovascular condition was normal, and the incision site looked healthy. Id.

         On January 5, 2011, Messina reported left-side knee pain that felt “identical to the pain he experienced when he had his right meniscal tear taken care of.” Id. at 271. On January 19, 2011, Dr. Belniak operated on Messina's left knee to repair a large tear in his medial meniscus. Id. at 287. On January 28, 2011, Messina reported his left knee pain was gone. Id. at 270. A postoperative ...


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