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Satterfield v. Berryhill

United States District Court, N.D. West Virginia, Clarksburg

January 16, 2018

STACIE JO SATTERFIELD, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          KEELEY JUDGE.

          REPORT AND RECOMMENDATION

          MICHAEL JOHN ALOI UNITED STATES MAGISTRATE JUDGE

         I. INTRODUCTION

         On November 18, 2016, Plaintiff Stacie Jo Satterfield (“Plaintiff), by counsel Jan Dils, Esq., filed a Complaint in this Court to obtain judicial review of the final decision of Defendant Nancy A. Berryhill, [1] Acting Commissioner of Social Security (“Commissioner” or “Defendant”), pursuant to Section 205(g) of the Social Security Act, as amended, 42 U.S.C. § 405(g). (Compl., ECF No. 1). On January 25, 2017, the Commissioner, by counsel Helen Campbell Altmeyer, Assistant United States Attorney, filed an answer and the administrative record of the proceedings. (Answer, ECF No. 6; Admin. R., ECF No. 7). On April 25, 2017, and May 24, 2017, Plaintiff and the Commissioner filed their respective Motions for Summary Judgment. (Pl.'s Mot. for Summ. J. (“Pl.'s Mot.”), ECF No. 15; Def.'s Mot. for Summ. J. (“Def.'s Mot.”), ECF No. 17). Following review of the motions by the parties and the administrative record, the undersigned Magistrate Judge now issues this Report and Recommendation to the District Judge.

         II. PROCEDURAL HISTORY

         Plaintiff initially filed an application for disability benefits on June 1, 2012 (R. 314), which was denied on September 5, 2012 (R. 141). Subsequently, on January 21, 2013, Plaintiff protectively filed an application under Title II of the Social Security Act for a period of disability and disability insurance benefits (“DIB”) alleging disability that began on September 20, 2010. (R. 291). Considering the prior denial and res judicata of same, the ALJ noted that Plaintiff was “willing to amend her alleged onset date” and considered Plaintiff's disability status beginning September 6, 2012. (R. 12). Plaintiffs earnings record shows that she acquired sufficient quarters of coverage to remain insured through June 30, 2015; therefore, Plaintiff must establish disability on or before this date. (R. 331). This claim was initially denied on March 15, 2013 (R. 142) and denied again upon reconsideration on April 22, 2013 (R. 156). On May 2, 2012, Plaintiff filed a written request for a hearing (R. 192), which was held before United States Administrative Law Judge (“ALJ”) George Mills on June 1, 2015 in Morgantown, West Virginia. (R. 59). Plaintiff, represented by counsel Yvonne Costelloe, appeared and testified, as did James Prim, an impartial vocational expert. (Id.). On July 16, 2015, the ALJ issued an unfavorable decision to Plaintiff, finding that she was not disabled within the meaning of the Social Security Act. (R. 35-58). On September 26, 2016, the Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. (R. 28).

         III. BACKGROUND

         A. Personal History

         Plaintiff was born on December 21, 1977, and was thirty-seven (37) years old at the time of the hearing. (R. 44). She completed high school and one year of college coursework (R. 46). Plaintiff's prior work experience included work as a bartender, customer service representative, billing clerk, home health aide, secretary, in-home parenting counselor, security guard, retail stocker, convenience clerk, and industrial cleaner. (R. 48-57). She was divorced at the time she filed her claim and at the time of the administrative hearing. (R. 59). She has one sixteen-year old daughter who lives with her, and one eleven-year-old daughter who lives with her father. (R. 1012). Plaintiff alleges disability based on degenerative disc disease from L3 - S1 and herniated/bulging discs in her back, supraventricular tachycardia (SVT), severe sciatic nerve damage in her back and legs, benign hyper tensity syndrome affecting joints, left knee problems, depression, anxiety, panic attacks, and bipolar disorder. (R. 114-115).

         B. Medical History

         1. Relevant Medical History

         On January 27, 2010, Plaintiff was seen by Dr. Cox at Mid-Ohio Valley Medical Group, at which time her low back pain was noted to have remained stable. (R. 562). Plaintiff continued to complain primarily of abdominal pain throughout 2011. In January 2012, imaging studies were ordered pursuant to Plaintiffs continued complaints of low back pain, and conducted on January 10, 2012. (R. 528). Referral to PARS was noted pursuant to “slight hyperlordosis of the lumbosacral spine [and] mild anterior spurring at ¶ 5.” Id.

         On January 23, 2012, Plaintiff again presented to Marietta Memorial ER with complaints of back pain, described as sharp and non-radiating. (R. 699). Plaintiff was given Morphine, Norflex, and Hydromorphone and discharged with instructions to follow up with the Spine Center the next day. (R. 700). Additional notes from Marietta Memorial Spine Center stated that:

Dr. Khosrovi has reviewed her MRI, lumbar. She does have some minor degenerative disk disease at ¶ 4-5 and LS-S1 but no significant neural compression and the C-spine is stable on flexion and extension. He has asked that the patient do a conservative treatment trial with physical therapy and should certainly include strengthening exercises, especially in light of Dr. Brar's note about injury avoidance and strengthening. If she continues to have muscular joint pain, can certainly see physiatry to discuss injections. If she fails physical therapy and physiatry, Dr. Khosravi has asked that she get a diskogram at 4-5 and 5-1 with 3-4 to be used as controls for her lumbar complaints. Will continue to case manage the patient and make certain that she gets the results.

(R. 691). On February 6, 2012, Plaintiff was seen by Gurpreet Brar, M.D. pursuant to complaints of “varying degrees of musculoskeletal discomfort involving her spine, shoulders, hips, and knees, [] consist[ing] of varying degrees of arthralgia and myalgia without any persistent redness, heat, or swelling affecting her joints” with variable morning stiffness. (R. 452). Physical examination was largely normal, except that Plaintiff satisfied Beighton's criteria for joint hypermobility. Id. Dr. Brar diagnosed “joint hypermobility involving the cervical spine, shoulders and elbows, thumbs and fingers, lumbar spine and both hips.” Id. On February 9, 2012, Plaintiff was seen by Benjamin Moorehead, M.D. at WVU Department of Orthopedics for her left hip pain, which “has been present for several months but [] significantly worse the last month.” (R. 615). Plaintiff reported that her pain was in her hip and groin, and was worse with prolonged sitting and hip rotation. Id. Physical examination revealed full range of motion, with paint at terminal internal rotation and external rotation; four out of five strength in the gluteus groups, tenderness in the lateral hip, no swelling, and a normal gait. (R. 616). Dr. Moorehead assessed left hip pain, snapping hip syndrome, and trochanteric bursitis of the left hip. Id. Dr. Moorehead recommended physical therapy. Id.

         A CT scan of Plaintiff's lumbar spine on April 13, 2012 revealed slightly decreased disc height at ¶ 4-L5, posterior disc bulge, and mild facet hypertrophy result[ing] in some stenosis of the neural foramina without interval change. (R. 684). The scan was ordered pursuant to Plaintiff reporting to the Marietta Memorial ER that day, complaining of vaginal, abdominal, and lower back pain after reporting she had fallen off a motorcycle. (R. 679). CT scans of Plaintiff's abdomen and cervical spine were unremarkable. (R. 686-88). Plaintiff was given Hydromorphone for pain and Zofran and discharged. Id.

         On April 30, 2012, Plaintiff presented to PARS Pain Center complaining of low back pain, which “developed gradually [beginning] several years ago.” (R. 461). Plaintiff reported the pain had been “constant, ” rated it eight out of ten in severity, and described the sensation as aching, stabbing, and burning. Id. She stated the pain radiated into her left leg. Id. She stated the pain was aggravated by sitting and walking, and alleviated by being in the upright position. Id. Plaintiff also reported numbness in her feet and hands. Id. She reported that Lyrica and Percocet had been effective; whereas Vicodin, physical therapy, epidural steroids, and chiropractic treatment were ineffective. Id. An MRI revealed broad-based disc protrusion at ¶ 4-5 measuring three millimeters in dimension and a small area of annular fissuring, mild facet arthropathy at ¶ 4-5, and a small left disc protrusion at ¶ 5-S1. Id. Physical examination of the lumbosacral spine revealed a positive straight leg raise test on the right, positive facet loading bilaterally, and positive 90/90 compression bilaterally. (R. 463). Range of motion, muscle strength and tone, and stability were normal. Id. Pin prick sensation testing revealed decreased sensation on the left. (R. 464). Gait and station were normal. Id. Plaintiff was assessed with low back pain, herniated nucleus pulposis at ¶ 5-S1, lumbar radiculitis, and myofascial pain. Id. A discogram under fluoroscopy was indicated, Id., which was subsequently performed at ¶ 3-L4, L4-L5, and L5-S1 on June 7, 2012. (R. 468).

         Plaintiff returned on August 29, 2012 and was seen by Dr. Khosrovi for continued complains of “pain, numbness and tingling, weakness, difficulty walking, and a difficulty with balance and coordination.” (R. 477). Dr. Khosrovi noted that:

[Plaintiff] has exhausted all conservative treatment and is convinced that she wants to proceed with surgery if there [is] even the slightest chance that she will be better. She has pain in her back and radiates into both legs worse on the left and all the way posteriorly to her ankles. She is very limited to what she can do before the pain is so severe that she has to lay down to get some relief.

(R. 478). Dr. Khosrovi reviewed imaging studies including an MRI, CT scan, and x-ray, and noted L4-5 and L5-S1 degenerative discs with left-sided small to moderate size paracentral herniations at both levels, which cause some compression of the descending L5 and S1 roots. Id. Dr. Khosrovi noted antalgic gait, standing without difficulty, and ambulation without assistance. (R. 482). Noting that Plaintiff's complaints and clinical presentation were consistent with diagnostic findings and that she had “exhausted all conservative treatment without any meaningful benefit, ” Dr. Khosrovi recommended that Plaintiff have a unilateral L4-L5 and L5-S1 discectomy with interbody cage placement, posterior instrumentation and fusion. Id. He cautioned Plaintiff that surgery was not guaranteed to relieve any or all of her symptoms, and on rare occasions has been found to make pain worse afterward. Id. Plaintiff did not have the recommended surgery at that time. Dr. Cox noted that Plaintiff was told she needed the surgery, and that she was requesting a second opinion from another doctor. (R. 512).

         On September 29, 2012, Plaintiff presented to Marietta Memorial Hospital complaining of low back pain radiating into her groin and legs, and numbness from her buttocks down her thighs, legs, and feet. (R. 644). She described the pain as sharp and rated it ten out of ten in intensity. Id. A physician's note indicates that she was scheduled for surgery but it was “on hold because of her insurance.” Id. The attending doctor's impressions included Cauda Equina Syndrome, lumbar strain, and degenerative disc disease, for which he ordered imaging. (R. 645). A lumbar MRI subsequently showed no evidence of Cauda Equina Syndrome, but showed the same disc protrusions and findings as before, except that “enlargement of an associated annular tear” was noted. (R. 646). Plaintiff was given pain medications and, once her pain was controlled, discharged. (R. 645).

         On November 8, 2012, Plaintiff was taken to Marietta Memorial Hospital after being found unresponsive. (R. 629). She was revived with Narcan and had no memory prior to waking up in the ambulance. Id. Plaintiff was “tearful and wanting to go home.” Id. Urine and blood screens were presumptive positive for amphetamines, benzodiazepine, and methadone. (R. 633, 639-40).

         On March 8, 2013, Plaintiff was seen at by Dr. Sanjay Bhatia, M.D. at West Virginia University Department of Neurosurgery for her back pain. (R. 601). She reported what Dr. Khosrovi had told her regarding the recommended discectomy surgery. Id. Her chief complaints at that visit included constant “left leg pain to left foot and numbness into left [big] toe on her left leg.” Id. Plaintiff reported that her pain was aggravated by intercourse, trying to have bowel movements, and being on her feet. (R. 601-602). She reported that physical therapy and injections had not helped. (R. 601). She reported that there were “no relieving factors.” (R. 602). Dr. Bhatia assessed [degenerative disc disease] and some disc protrusion as left L-5 subarticular foraminal region.” Id. Dr. Bhatia recommended a selective nerve block (left L-5) and imaging of Plaintiff's spine, then followup. Id.

         A CT scan of Plaintiff's thoracic spine conducted on May 10, 2013 was unremarkable. (R. 604). The recommended left L5 lumbar nerve block was completed that same day; afterward, Plaintiff “reported minimal relief of pain.” (R. 606). Examination revealed decreased sensation in her left lower leg. (R. 601-02). She was given a transforaminal injection in the lumbar spine. (R. 605-06).

         On June 16, 2013, Plaintiff returned to Marietta Memorial complaining of a headache, generalized, rated ten out of ten in intensity of pain. (R. 880). Despite that, Dr. Dinh Vu noted that Plaintiff “appear[ed] completely comfortable during [the] interview and exam.” Id. The week prior, she had been seen there for reports of seizures, for which imaging studies were ordered. Id. Dr. Vu observed that the EEG was unremarkable, the CT scan of her head was normal, and that on neurology consult, Dr. Louden referred Plaintiff back to her psychiatrist for treatment of psychogenic non-epileptic seizures (“pseudoseizures”). (R. 881). ER notes emphasized that Plaintiff “has been here several different times pertaining to [the] same issue, ” with onset five days ago, described as moderate, non-radiating headaches that were “constant, throbbing, bilateral, frontal and occipital headaches.” (R. 885). Terry Carr, D.O. noted that Plaintiff “was seen here yesterday and pain [was] better after [given a] blood patch and two milligrams of Dilaudid” (Hydromorphone). Id. Plaintiff was given more Hydromorphone and discharged. Id. An MRI of Plaintiff's brain found “scattered T2/FLAIR signal abnormality in the subcortical white matter of the left frontal [lobe], ” but no other abnormalities. (R. 893).

         In July 2013, Plaintiff returned to Dr. Bhatia stating she “is getting worse . . . [and] is at her witts [sic] end and wants something done.” (R. 895). observed that recent imaging showed degenerative disc disease, but did not feel Plaintiff was a candidate for surgery at that time. (R. 898). On July 26, 2013, Plaintiff reported that the pain was “starting to go down the right leg now” in addition to radiating down her left leg. (R. 807). Dr. Bhatia opined Plaintiff was “not a candidate for surgery” because the “imaging shows . . . [no] canal or formainal stenosis.” (R. 808). Plaintiff reported that another physician told her that she could benefit from a fusion, so Dr. Bhatia referred her to Dr. Meile for a second opinion. Id. Dr. Bhatia wrote a prescription for Norco (acetaminophen hydrocodone). Id.

         On August 26, 2013, Plaintiff was revived from an overdose at Marietta Memorial, characterized as a suicide attempt pursuant to suicidal intention. (R. 853). A urine screen was positive for methadone, opiates and benzodiazepine. Id. Todd Hawkins, M.D. performed a psychological consult following these events. (R. 857). Pursuant to a mental status examination, Hawkins stated Plaintiff was a “very depressed-appearing lady,' who was “emotionally labile, crying, yelling, almost irrational.” (R. 858). Mood was dysphoric; affect was restricted. Id. Speech was clear and thought process was coherent. Id. Hawkins noted that Plaintiff had admitted suicidal ideation the previous day, but denied it at that time. Id. Hawkins noted that Plaintiff “requires inpatient psychiatric treatment and substance abuse treatment; [although] reluctant to be admitted, [she eventually] agreed.” Id. Plaintiff was subsequently sent to an inpatient Psychiatric Hospital. (R. 853). Hawkins advised that releases be sent to her psychiatrist and primary care doctor to advise against prescribing any controlled substances, as “they would certainly be contraindicated in this lady with a terrible substance abuse problem.” (R. 858).

         On September 20, 2013, Plaintiff was taken to Marietta Memorial ER unresponsive pursuant to overdose. (R. 819). A urine screen was positive for marijuana, amphetamine, and methadone. Id. Plaintiff was revived with Narcan. Id. On September 22, 2013, David Hill, M.D. completed a psychological consultative evaluation of Plaintiff pursuant to her most recent overdose. (R. 824). Dr. Hill noted that Plaintiff was “sent to Charleston” for five days following her overdose, when she was “much angrier and less cooperative.” Id. A mental status examination revealed Plaintiff to be alert, cooperative, and pleasant. Id. Speech was relevant, coherent, and spontaneous. Id. Plaintiff was oriented and memory was normal. Id. Diagnostic impressions included “probably polysubstance abuse, mild-to-moderate, ” and “bipolar disorder, depressed by history.” (R. 825).

         On October 15, 2013 Plaintiff presented to Dr. Cox complaining of ankle pain lasting for four days. (R. 1050). Physical examination revealed tenderness on palpation over the anterior talofibular ligament on Plaintiff's left ankle. (R. 1052).

         In October 2013, Plaintiff was involved in an accident in which her vehicle rolled over. (R. 777). Imaging showed fracture of the right transverse processes of L1 to L5 vertebral bodies, right 8th and 9th rib fractures, nondisplaced fracture of the right hip, fracture of the right sacrum, and degenerative disc disease at ¶ 4-5 with desiccation with a central annular tear.” (R. 781-782). (ECF No. 16 at 7). Dr. Levy noted that the transverse process fractures are “clinically insignificant and are not surgical, ” and that none of the findings necessitated surgery but should be treated by wearing a brace. (R. 779).

         On November 3, 2013, Plaintiff reported back to the Marietta Memorial ER complaining of pain in her legs that felt like “pins and needles.” (R. 806). She stated the Percocet Dr. Levy gave her was not helping, and her pain had increased in the last couple of days. Id. Imaging of Plaintiff's pelvis that day revealed “no convincing acute fracture within the pelvis.” (R. 816). Plaintiff was given Hydromorphone, Valium, and Decadron and discharged. (R. 811).

         Later that same day, on November 3, 2013, Plaintiff returned to WVU complaining of “increased pain, [] weakness and numbness to the [bilateral] legs, [worse on the right].” (R. 924). She reported that imaging earlier that day at a different hospital showed “increased compression and hematoma” without bowel or bladder symptoms. Id. Plaintiff's right leg evidenced subjective decrease in sensation and reduced strength (4/5) compared to her left leg, and that imaging showed a “jumped facet.” Id. Plaintiff reported pain at nine out of ten (9/10) initially, reduced to seven out of ten (7/10) after Plaintiff was given eight milligrams of morphine, five milligrams of valium, and .12 milligrams of hydromorphone. (R. 926). An MRI of Plaintiff's lumbrosacral spine showed the following:

FINDINGS: As noted on the recent CT of the thoracic spine had demonstrated a right L1 transverse process fracture. There is corresponding bone marrow edematous changes are noted to the right transverse process of L 1. There is new levocurvature noted of the lumbar spine as a result of traumatic injury to the L5 vertebral body. [T]here is bone marrow edematous changes identified to be L5 vertebral body, with asymmetric loss of vertebral body height noted to the lateral aspect. There is also traumatic disc herniation extending to the right lateral recess and this severe right lateral recess stenosis. Edematous changes are noted to be posterior paraspinal soft tissues the conus terminates at a normal level. The cauda equina nerve roots appear unremarkable except at the L5-S1 level where they are compressed . . .
At the L5-S1: Atraumatic right paracentral and right foraminal herniation resulting in severe right lateral recess and right foraminal stenosis with compression of the exiting nerve root. Also noted is asymmetric loss of vertebral body height along the left lateral aspect. In addition there is fractures of the posterior elements evident with suggestion of malalignment of the facets on the right (jumped facet) as noted on the axial image 35, series 10.

(R. 947-48). An MRI of Plaintiff's lumbar spine showed the following:

Findings: There is demonstration of fracture involving the right posterior elements with evidence of a jumped facet seen best on series 9 image 63. There is fracture of the right L5 vertebral body with additional fractures noted in the bilateral L5 transverse processes. There is narrowing of the spinal canal at the L5-S1 level due to a traumatic disc herniation, right-sided jumped facet, and degenerative change. There are additional fractures noted: The right L1, L2, L3, and bilateral L4 transverse processes. Impression: Traumatic loss of height involving the inferior aspect of the L5 vertebral body asymmetrically on the left with a right-sided jumped or perched facet, traumatic disc herniation and several fractures involving the transverse processes of the lumbar spine as discussed above.

(R. 949). On November 5, 2013, Daffner performed back surgery, including an “open reduction of the facet dislocation with a hemilamenictomy and discectomy for treatment of the traumatic disc herniation and radiculopathy and posterior fusion.” (R. 917). He noted Plaintiff “tolerated the procedure well, ” and was discharged on November 9, 2013 with follow-up in two weeks. (R. 932).

         At follow-up on November 22, 2013, Plaintiff reported she was “doing okay, ” but fell onto her buttocks earlier that morning and still had some persistent leg pain and numbness. (R. 952). She reported taking two Percocet tablets every six hours. Id. Dr. Daffner reminded her not to be lifting more than five to ten pounds, and that she should not bending or twisting excessively. Id. Dr. Daffner noted that an x-ray revealed “appropriate spinal alignment ha[d] been restored . . . [and] interval increase in L4-L5 and L5-S1 disc space loss is noted.” (R. 954).

         On December 9, 2013, Plaintiff returned complaining of increased weakness in her left leg, stating her left leg “gave out” on her earlier that day, since which point she has had “increasing pain and numbness in a widening distribution.” (R. 954). X-rays, MRIs and CT scans revealed that “hardware is intact, alignment maintained, [there was] no new fracture, [and] no hematoma or compressive lesion.” (R. 957). There was “some moderate left L5-S1 foraminal stenosis.” Id. Plaintiff returned two days later to WVU reporting she had “slipped and jerked her body to the left” while out on her porch. (R. 958). Since then, she complained of “difficulty walking, with pain in her lower back, left hip into groin, and left leg numbness.” Id. Imaging showed “no spinal stenosis or abnormal mass or fluid collection in the spinal canal . . . [and] no enhancing fluid collections to suggest soft tissue abscess, [but] subtle enhancement of the left L4 nerve root . . . with inflammation.” (R. 961). Plaintiff was given injections of Fentanyl and Hydromorphone. Id.

         Plaintiff returned again on December 23, 2013 complaining again of frontal headache and back pain. (R. 975). She told staff that “the pain medication she is receiving is to[o] little.” (R. 976). Plaintiff was kept overnight for observation:

Pseudoseizures
- At 2027 on 12/23 after photic stimulation patient eyes looked almost crossed eye and passed out. Also at 2110 patient pushed button and stated she was almost asleep and her heart started beating so hard she felt like it was "jumping out of her chest". Also became shaky and had a 3 second flattening on EKG. Don't know if it was artifact. Again at 2232 on 12/23 patient was being helped to the restroom when she felt dizzy and lightheaded like she was going to pass out. Patient collapsed at bed but didn't lose consciousness.

(R. 979). She rated her pain at that visit as a five out of ten (5/10). (R. 982). Examination was generally normal with the exception of decreased sensation in her lower left leg, and “patchy” decreased sensation to touch and pin in her bilateral thoracic region. (R. 983). An EEG on December 24, 2013 was normal. (R. 989).

         On January 17, 2014, Plaintiff was taken to UPMC after overdosing in her home, which was classified as a suicide attempt. (R. 1404). She did not regain consciousness until January 26, 2014 and was intubated during that time. (R. 1375). Notes from attending physicians reported that Plaintiff had been overwhelmed by stressors:

Pt reports that she is feeling very "pissy'' today for multiple reasons. She states that she has not been feeling well for some time now and has noted no changes thus far after reinitiation of effexor. She describes how she is upset that she is on a trach that she lost custody of her younger daughter, and that her younger daughter's father cheated on her with her best friend. She reports she was also taking lamictal prior to her overdose and endorses that this is the second suicide attempt after her MVA this past year. She states she is always in pain (points to knee, back) and that no one believes her pain.

(R. 1617).

         On March 6, 2014, Plaintiff was seen at Mid-Ohio Valley Medical Group by Dr. Cox to reestablish primary care following her discharge from UPMC Hospital on February 19, 2014. (R. 10). She reported being sober for two-hundred and twenty-one (221) days, but Dr. Cox noted she was “not working in a recovery program nor did she go to pain management that we arranged.” (R. 1036). Dr. Cox advised Plaintiff to start AA/NA meetings and get sponsorship.

         On March 26, 2014 Plaintiff complained of worsening anxiety. (R. 1041). CMA Mary Bailey wrote she would “forward [the] message to Dr. Cox [to] consider increasing medication, ” noting that Plaintiff was “not interested in other treatments for anxiety, [and] does not want to see counselor or [be] referred.” Id.

         On April 9, 2014, Dr. Daffner saw Plaintiff five months post-operatively. (R. 1270). She continued to complain of low back pain, which she had prior to her surgery; ongoing left leg numbness, a “shifting” pelvis, and popping in her left hip. Id. Plaintiff claimed to not be taking any medication other than Tylenol and Motrin at that time. Id. Dr. Daffner noted that a tracheostomy scar was “new since the last time [he] saw her.” Id. He noted that “when [he] asked [Plaintiff] about this, she declined to provide any further details.” Id. By May 7, 2014 Plaintiff continued to report “severe pain out of proportion [] since the time of surgery.” (R. 1276). Plaintiff was “in no acute distress [and] appear[ed] to be a little uncomfortable due to her pain.” Id. Dr. Daffner noted he “ha[d] been unable to localize anything specific that I think is causing the pain, ” and noted he would check for infection and vitamin D levels. Id. He additionally noted that he was “concerned about the maturation of her fusion and the loosening around the screws, but they certainly have not pulled out at this point.” Id. Dr. Daffner again told Plaintiff that “she needs to stop smoking as this can delay her bone healing.” (R. 1277). He further observed that at that time Plaintiff was hyperreflexic and had a positive Hoffman's reflex, and reported changes in her handwriting, difficulty with fine motors skills, and several falls. (R. 1277). Daffner noted an MRI should be rechecked to evaluate for myelopathy. Id. Daffner noted that he did not have a good explanation for “why [Plaintiff] feels that hips are unstable when she walks.” Id. He lastly noted that Plaintiff requested pain medication, which he declined as “[he] will not be prescribing her any narcotic pain medication” six months post-operatively. (R. 1277). Dr. Daffner referred Plaintiff to the pain clinic at WVU for “long-term nonoperative treatment” and suggested that she keep the appointment with Dr. Gross in pain psychiatry. Id.

         On November 14, 2014 Plaintiff returned to the ER with complaints of low back pain. (R. 1147). X-ray imaging showed “possible loosening of pedicle screw.” Id. Plaintiff was given pain medication and told to follow up with Dr. Daffner and her primary care doctor. Id. Marietta Memorial attending staff called Dr. Daffner, “who agree[d] with outpatient [treatment] and can [followup] with patient in [his] office.” Id. Imaging studies taken November 24, 2014 showed “extensive lucency surrounding the bilateral pedicle screws at ¶ 4, worrisome for hardware loosening.” (R. 1149). “No definite evidence of hardware fracture was observed. Id.

         On November 29, 2014, Plaintiff returned to the WVU Hospital ER with back pain, worsening in the past three weeks and getting “much worse” in the past three days. (R. 1185). Imaging studies again revealed no evidence of hardware fracture, but increase in intervertebral disc height loss between L3 and L4; “markedly increased lucency around the L4 screws bilaterally compared to May 2014 [was] concerning for hardware loosening” (R. 1189); lucency surrounding the L3 transpedicular screws suggest hardware loosening.” (R. 1187). Shabnam Nourparvar, M.D. told Plaintiff that she should be admitted pursuant to blood and urine tests results that showed gram negative - i.e., antibiotic-resistant - bacteria growth. (R. 1190). Plaintiff declined admission and left against medical advice because “her ride [was] here and [she] would rather go home and follow up with ortho[pedics] in two days.” (R. 1190). Plaintiff was given antibiotics and discharged. Id.

         She went back to WVU Orthopedics on November 30, 2014, at which point Dr. Bravin and Dr. Daffner's notes stated that MRI “does not show any evidence of discitis, osteomyelitis, psoas or epidural abscess.” (R. 1214). Accordingly, “no surgical intervention [was] recommended at this time.” Id. Orthopedics noted that Plaintiff said she “wants her screws out, ” but that can be managed on an outpatient basis and “there are no urgent surgical needs currently.” Id.

         On December 1, 2014, Dr. Daffner's interpretation of the imaging studies was “loosening of the L4 screws and lucency surrounding the L3 transpedicular screw.” (R. 1224). He discussed Plaintiff's options with her, advising they could do a disc space biopsy at ¶ 3-L4 and L5-S1, a revision of the fusion, or an injection over the hardware to see if that provided relief. (R. 1225). He also advised that removal could result in the entire construct “fall[ing] apart” and any surgery would “come with a significant risk of failure.” Id. Dr. Daffner advised Plaintiff that she would have to quit smoking, which she agreed with. Id.

         On December 3, 2014 Plaintiff was admitted to Marietta Memorial with back pain. (R. 1065). An MRI revealed osteomyelitis and early discitis at ¶ 3-L4; Plaintiff also had bacteremia and a urinary tract infection. Id. The attending physician noted that Plaintiff's blood culture grew “strep mitis;” Plaintiff ‘denied [a] history of endocarditis or [intravenous] drug use, ” as her past overdoses involved only pain pills. (R. 1069). These findings and conditions did not require any procedures, apart from placement of a PICC line so Plaintiff could continue antibiotic treatment after discharge. (R. 1065). Christopher Cockerham, M.D. noted that “[he] had a long discussion with [Plaintiff] about the need to make sure that she keeps [t]his PICC line clean; she is not to inject any medications or illicit drugs into her PICC line other than IV antibiotics.” Id. Notes from December 4, 2013 stated that Plaintiff recently left the WVU facility against medical advice after being transferred there from Marietta Memorial ER on November 28, 2014. (R. 1067). Plaintiff continued to “decline transfer back to WVU due to the distance and want[ed] a second opinion/evaluation at MMH.” (R. 1068). Dr. Levy further noted:

The patient does not have an epidural abscess and indeed she also does have bacteremia which of course is the reason she apparently has this infectious process going on. The issue, which I did discuss with her at some length, is why what is the etiology of this infection, most commonly this is seen with immunosuppressants or IV drug abuse and she does not have either of these issues going on. At any rate, she does have this apparent infection without a clear etiology behind it

(R. 1071).

         On December 7, 2014, Plaintiff reported again to Marietta Memorial with complaints of worsening lower back pain beginning the day prior. (R. 1105). She described it as gradual in onset and progressively worsening, radiating toward the right side and down her leg. (R. 1106). The pain was made worse by “any kind of movement.” Id. The attending physician noted that Plaintiff “was lying in bed talking on her phone when I entered the room, [and] didn't appear to be in any significant distress [during] my evaluation.” Id. He further related that:

She has a prior history of drug overdose as well as drug abuse in the past. She is also apparently had suicidal attempts. Because of this past history pain medication is very carefully prescribed to her. This is not done by her primary care physician and she primarily gets her pain medications from her neurosurgeon that she sees Morgantown. She hasn't had a refill of the same. Doesn't want to be on pain medications and so we discussed at length about trying nonnarcotic pain medications to see the mass pain can be controlled and she is open to the idea.

Id. Imaging studies done that day revealed “[no] acute changes from previous study.” (R. 1116). Plaintiff was “offered transfer[] to WVU for followup care with her orthopedic surgeon but declined, stating she would rather stay here.” Id.

         On December 16, 2014 Plaintiff was seen again as Marietta Memorial with complaints of pain, weakness and numbness in her lower left leg and bowel incontinence. (R. 1089). She reported having difficulty walking and using a case for the last few days. Id. She reported that her pain is improved with pain medication. Id. MRIs revealed the following:

1. MRI findings are again most compatible with discitis/osteomyelitis associated with the L3/L4 level.
There has been marginal interval expansion of the fluid collection in the disc space at this level.
Otherwise, the appearance of the lumbar spine is not significantly changed from 12/7/2014.
2. No evidence of epidural abscess or canal compromise.

(R. 1102). She was transferred to WVU for treatment. (R. 1096). She presented again to WVU Orthopedics with continued complaints of low back pain as well as reports of two episodes of bowel incontinence. (R. 1238). Plaintiff was given Percocet, Hydromorphone, and “pain-dose” Ketamine, which were noted to have resolved her back pain, and discharged. (R. 1242). On December 30, 2014, Dr. DiGiovine completed an intervertebral disc aspiration and sent a tissue and fluid sample to the lab for evaluation. (R. 1264).

         At followup with Dr. Daffner on January 21, 2015, he noted that Plaintiff continued to have back pain which “seems to be getting a lot worse, ” and that “she appears to be quite uncomfortable.” (R. 1288). Daffner noted that Dr. DiGiovine's sample came back consistent with Candida tropicalis. Id. In addition to continued lucencies around the L4 screws, imaging studies also revealed “significant collapse and destruction of the disk space at ¶ 3-L4 . . . destruction of the endplates with some retrolisthesis of L3 on L4 as well as some lateral listhesis and asymmetric collapse.” Id. Dr. Daffner admitted Plaintiff for placement of a PICC line and antibiotic treatment and caspofungin, and referred her for an infectious diseases consult. Id. He noted that “in all likelihood she will need surgical intervention for this given the evidence of instability and kyphosis.” Id. Surgical plans included posterior removal of hardware, exploration and revision of fusion L2-pelvis, then “anterior L3 and L4 debridement of discitis/osteomyelitis and fusion.” (R. 1294).

         Plaintiff underwent the first stage of the procedures on January 24, 2015 including the removal of hardware and exploration. (R. 1297). On January 27, 2015 Plaintiff underwent a second set of procedures including L3-4 partial corpectomies, debridement and fusion. (R. 1300). Following these surgeries, Plaintiff was “doing well, [with] pain moderately controlled [and] left thigh numbness improving.” (R. 1301). She generally continued to do well until she was deemed ready for discharge on February 2, 2015. (R. 1318). Plaintiff was walking with assistance and pain was controlled with medication. Id. At followup on February 9, 2015 Plaintiff was progressing as expected and “doing well” overall. (R. 1365-66). Dr. Daffner encouraged Plaintiff to begin to wean off narcotic pain relievers, to keep her infectious disease consult appointment, and to stop smoking because it was important to help her bone fusion. Id. At next followup on March 13, 2015, Plaintiff continued to do well overall and reported although she had some pain from the operation, the pain from her discitis had “improved significantly.” (R. 1367). She reported being ready to transition to using a cane from a walker. Id.

         However, on May 20, 2015, Plaintiff returned to the Marietta Memorial ER complaining of worsening back pain over the past week. (R. 1878). She advised the attending physician that she had fevers of 102 degrees over the weekend and her surgeon instructed her to go to the nearest emergency department. Id. CT scan revealed the following:

…bilateral evidence of construction failure including bilateral screw loosening at ¶ 2 and tight school loosening at ¶ 3 as well as fracture of right pedicle at ¶ 2. Interval placement of longitudinal struck graft in L3-L4 with significant bone formation about the new formation resultant mass effect on ventral thecal and narrowing of lateral recess at level of this case. Multilevel degenerative changes and lumbar spine. Peripherally enhancing fluid collection in posterior soft tissue presumably postoperative could represent infectious collection.

(R. 1886). Plaintiff was transferred to WVU from Marietta Memorial for further evaluation and management, where she again saw Dr. Daffner on April 20, 2015. (R. 1887). Dr. Daffner reviewed the imaging and agreed that the L2 screws did appear to have “cut out some superiorly since the initial placement . . . their alignment has not changed, however, since her previous x-rays on March 9, 2015:”

PLAN: Dr. Daffner discussed today with Ms. Satterfield that overall looking at her x-rays, they look good. The superior screws did appear to pull out some; however, they are stable and we do not see any motion through this area. We do not think that any particular treatment would be appropriate for her at this time. She does not really seem to be symptomatic from that anyways. She describes the pain more in the soft tissues and it does not follow any definite pattern, but rather extends down the posterior aspect of the thighs. We do want to get her in some formal physical therapy including core strengthening and conditioning, stretching of the lower extremities and they can do some modalities on the lower extremities as well. We are going to see her back in Dr. Daffner's clinic in 3 months. We will refill her Percocet but decrease the dose to Percocet 5 mg every 4-6 hours as needed for pain. She needs to understand that we will be weaning her off of this over the next month and a half or so, as we typically do not give pain medication more than 3 months after surgery. She has been on chronic narcotics for quite some time and after we have weaned her off, then we will ask that she get further prescriptions for chronic pain medications from either her primary care physician or a pain clinic.

(R. 1901-02). On April 30, 2015 Plaintiff attended her infectious disease consult appointment with Dr. Guilfoose who noted that she was “doing well overall.” (R. 1907). She was taking Diflucan for her candida infection, which caused some nausea, but overall was tolerated well. Id. She reported continuing back pain and radicular symptoms averaging “7-8/10 pain most . . . days, ” though she “does not expect to be pain free.” Id. Guilfoose noted that Plaintiff was gaining weight again; she had lost weight when the infection was active. Id. She denied fevers, and her surgical wounds were observed to have healed well. Id.

         On May 21, 2015, however, Plaintiff returned to the WVU ER for low back pain radiating down both legs, bilateral leg weakness and fevers, slowly worsening over one week. (R. 1910). Dr. Daffner noted:

I had a long discussion with her regarding her findings. No acute surgical intervention needed. We discussed the loosening of the screws and the possible development of pseudarthrosis. We also discussed the likelihood that she will need another revision procedure extending her fusion proximally. I explained to her that she absolutely must stop smoking and be tobacco/nicotine free for at least 4 weeks pre-operatively and for at least 6-12 months postoperatively. In addition, her vitamin D must also be normal (between 40-60) before we can consider surgery. She expressed understanding.

(R. 1920). Imaging studied obtained that same day show that “hardware and alignment appear stable when compared with prior studies.” (R. 1943).

         2. Medical Reports/Opinions

         a. Consultative Psychological Examination

         On July 16, 2012, Amy Guthrie, M.A. and Frank Bettoli, Ph.D., completed a consultative Psychological examination consisting of a clinical interview and mental status examination. (R. 454). Guthrie summarized Plaintiff's symptoms as follows:

PRESENTING SYMPTOMS: Stacie sleeps with the aid of medication and indicates that some nights it does not help her to sleep. The anxiety often keeps her up as she has racing thoughts. She has been having crying spells on an almost daily basis for the past couple of years. Her energy level has been low for the past couple of years and she reports that it was usually high in the past. Her appetite is decreased and she has lost about 70 pounds over the last year. She describes her mood as "not great." She finds that her depression varies in intensity and duration and has lasted for a couple of months before. Stacie admits to having occasional suicidal ideation with no plans to harm herself. She does not have the history of suicide attempts. She denied any homicidal ideation.
Stacie endorses anxiety in which she worries excessively and reports that this worry does keep her awake. She finds it hard to relax and often feels emotionally drained. She does have panic attacks when she is in crowds or knows she must leave her house. She does not like to be around people she does not know and does not like people touching her in a crowd. Stacie did report a history of sexual abuse by her stepfather and states that she had not told anyone about this until recently. She has noticed that her nightmares and flashbacks have increased since telling about the abuse. She was also physically and mentally abused by her ex-husband.

(R. 455). As to the mental status evaluation, Guthrie noted Plaintiff's appearance was adequate and verbal and physical domestic abuse as an adult. (R. 458). Symptoms include nightmares and flashbacks of these events four to five times per week, avoidance of situations that remind her of the abuse, problems in relationships, anxiety around men, and feeling that she “must watch her back when out in public.” Id. Guthrie believed Plaintiff's anxiety relating to being out in public and around people is a result of the past abuse. Id. Major Depressive Disorder (recurrent, severe, without psychotic features) was also diagnosed. (R. 458). Symptoms included sleep disturbance, daily crying spells, low energy lasting for the past couple of years, decreased appetite leading her to have lost about seventy (70) pounds over the past year, and periods of depression of varying intensity lasing up to two months at a time. Id. Generalized Anxiety Disorder was diagnosed, pursuant to excessive worry that Plaintiff is unable to control, that keeps her awake, makes it hard to relax, and leaves her feeling “emotionally drained and tense.” Id. Symptoms also included “becom[ing] overly anxious when [Plaintiff] thinks about leaving her home . . . she often chooses to stay home rather than go out into [the] public.” Id.

         Guthrie opined that Plaintiff was capable of managing her finances. (R. 458). She also opined that Plaintiff's prognosis was “guarded, due to abuse history.” Id.

         b. Disability Determination at the Initial Level

         Plaintiff was found to have the following severe medically determinable impairments: disorders of the back (discogenic and degenerative), cardiac dysrhythmia, anxiety disorder, and affective disorder (depression). (R. 119). It was determined that one or more of Plaintiff's medically determinable impairments could reasonably be expected to produce her pain or other and appropriate, her attitude was cooperative, and she was oriented times four. (R. 456). Speech was “coherent and relevant, but notably shaky.” Id. Plaintiffs mood was depressed and anxious; her affect was restricted. Id. Thought processes were coherent. Id. As to perception, Guthrie observed that:

Stacie reports periods of depersonalization in which she zones out when she is highly stressed. She also reports having flashbacks about the sexual abuse by her stepfather as well as verbal and physical abuse by her ex-husband. She finds that she avoids situations that remind her of the abuse, she has problems in relationships, she is anxious around men, and she finds herself watching her back in public.

(R. 457). Insight was mildly deficient; judgment was within normal limits. Id. Psychomotor behavior was “mildly increased, as [Plaintiff] wr[u]ng her hands and fidget[ed] throughout the evaluation.” Id. Plaintiff reported occasional suicidal thoughts with no plan. Id. Immediate memory was within normal limits; recent memory was moderately deficient, and remote memory was within normal limits. Id. Concentration was mildly deficient as Plaintiff could not complete serial sevens. Id. Persistence was within normal limits; pace was “mildly slow.” Id. Social functioning was mildly deficient. Id. Guthrie observed that Plaintiff was “noticeably close to tears multiple times throughout the evaluation, but would not allow herself to cry.” Id. Eye contact was adequate, though she was “notably nervous.” Id.

         Plaintiff reported she has friends she talks to about two times a week, at her house or theirs, and she talks to her mother on the phone. (R. 457). She does not drive often but walks to her mother's or her cousin's houses. Id. She sits on her porch, watches television, and listens to music. Id. She takes her daughters to cheerleading practice. Id. Plaintiff reported that she generally does make dinner, and cleans, washes dishes, and does laundry. Id. She goes grocery shopping once a month, “but goes at odd times to avoid crowds.” Id. She reported disrupted sleep, in that she is “up and down through the night.” Id. Plaintiff “admit[ted] that she has sometimes gone up to two to three days without caring for her hygiene.” Id.

         Chronic Posttraumatic Stress Disorder was diagnosed as a result of childhood sexual abuse. (R. 120). As to Plaintiff's credibility, the disability determination first stated that Plaintiff's statements about the intensity, persistence and functionally limiting effects of symptoms were not substantiated by the objective medical evidence alone. (R. 121). On the next line, Plaintiff's statements regarding her symptoms, considering the total medical and non- medical evidence in the file, were deemed “fully credible, ” with the note “Claimant's allegations are generally consistent with objective evidence.” Id.

         On March 14, 2013, single decision-maker (SDM) Jonathan Merrifield reviewed Plaintiff's records and completed a physical residual functional capacity (“RFC”) assessment. (R. 123). Merrifield found the following exertional limitations: Plaintiff could occasionally lift and/or carry twenty (20) pounds; frequently lift and/or carry ten (10) pounds; stand, walk, and/or sit for about six (6) hours in an eight (8) hour workday; and could engage in unlimited pushing and/or pulling, within her lift/carry restrictions. (R. 121). As to postural limitations, Merrifield found that Plaintiff could occasionally climb ramps and stairs, never climb ladders, ropes, and scaffolds; and occasionally balance, stoop, kneel, crouch, and crawl. (R. 121-22). He noted that the restrictions were supported by her “[h]istory of syncope, [she] should avoid heights and hazards, ” and that she was “otherwise restricted by lumbar radiculitis.” (R. 122). No manipulative, visual, or communicative limitations were found. Id. As to environmental limitations, Plaintiff could have unlimited exposure to extreme temperatures, wetness, humidity, noise, vibration, fumes, odors, dusts, gases, and poor ventilations; and should avoid all exposure to hazards. Id. Merrifield ultimately opined that Plaintiff was capable of a restricted range of light work. (R. 123).

         On March 15, 2013, agency reviewer Frank Roman, Ed.D. reviewed Plaintiff's records and completed Psychiatric Review Technique (“PRT”) and Mental Residual Functional Capacity (‘MFRC') assessments. (R. 120, 123). Roman found mild restriction of activities of daily living; moderate difficulties in maintaining social functioning; mild difficulties in maintaining concentration, persistence, or pace; and no episodes of decompensation of extended duration. (R. 120). As to social interaction limitations, Roman found Plaintiff was moderately limited in her ability to interact appropriately with the general public, and her ability to accept instructions and respond appropriately to criticism from supervisors. (R. 123). Social interaction limitations were supported by her history of depression and PTSD from past abuse; Roman noted that Plaintiff was uncomfortable in public and preferred to limit social interactions, especially after heart surgery. (R. 123-24). Ultimately, Roman opined Plaintiff was “able to follow routine 1-2 step duties in a low pressure setting with initial supervision, [could] tolerate occasional social interaction in a small setting, [and could] adapt to a basic routine and meet clear cut goals.” (R. 124).

         c. Disability Determination at the Reconsideration Level

         On reconsideration, the determination indicated no new conditions, no new physical or mental limitations, no change in existing conditions, and noted that Claimant “does not report any new evidence” since the initial determination. (R. 129). At reconsideration, the determination again stated that Plaintiff's statements about the intensity, persistence and functionally limiting effects of symptoms were not substantiated by the objective medical evidence alone, but also that Plaintiffs statements regarding her symptoms, considering the total medical and non-medical evidence were “fully credible” and “generally consistent with objective evidence.” (R. 134).

         On April 10, 2013, agency reviewer Fulvio Franyutti, M.D. reviewed the prior RFC assessment and affirmed it as written. (R. 136). On April 10, 2013, agency reviewer Ann Logan, Ph.D. reviewed the prior ...


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