United States District Court, N.D. West Virginia, Clarksburg
REPORT AND RECOMMENDATION
MICHAEL JOHN ALOI UNITED STATES MAGISTRATE JUDGE
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,
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
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).
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).
Relevant Medical History
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 ¶
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
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
(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.
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.
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).
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).
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).
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).
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.
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).
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.
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).
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).
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).
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.
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).
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.
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
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.
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).
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.
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
- 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
(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).
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.
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.
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.
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
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.
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.
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.
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.
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
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.
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
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.
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).
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.
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
(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.
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.
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
(R. 1920). Imaging studied obtained that same day show that
“hardware and alignment appear stable when compared
with prior studies.” (R. 1943).
Consultative Psychological Examination
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.
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.
Disability Determination at the Initial
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
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
(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.
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.”
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.”
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).
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).
Disability Determination at the Reconsideration
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).
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 ...