United States District Court, D. South Carolina
Lynette L. Nelson, Plaintiff,
Andrew M. Saul,  Commissioner of Social Security Administration, Defendant.
REPORT AND RECOMMENDATION
V. Hodges United States Magistrate Judge.
appeal from a denial of social security benefits is before
the court for a Report and Recommendation
(“Report”) pursuant to Local Civ. Rule
73.02(B)(2)(a) (D.S.C.). Plaintiff brought this action
pursuant to 42 U.S.C. § 405(g) and § 1383(c)(3) to
obtain judicial review of the final decision of the
Commissioner of Social Security (“Commissioner”)
denying her claim for an earlier onset of Disability
Insurance Benefits (“DIB”). The two issues before
the court are whether the Commissioner's findings of fact
are supported by substantial evidence and whether he applied
the proper legal standards. For the following reasons, the
undersigned recommends the Commissioner's decision be
April 23, 2014,  Plaintiff protectively filed a claim
for DIB in which she alleged her disability began on March
25, 2014. Tr. at 75, 84. Her application was denied initially
and upon reconsideration. Tr. at 103-07, 110-14. On January
26, 2017, Plaintiff appeared for a hearing before
Administrative Law Judge (“ALJ”) Edward T.
Morriss. Tr. at 35-73 (Hr'g Tr.). The ALJ issued a fully
favorable decision on March 24, 2017, finding Plaintiff to be
disabled as of her alleged onset date. Tr. at 19-31. On
January 16, 2018, the Appeals Council denied Plaintiff's
request for review, making the ALJ's decision the final
decision of the Commissioner for purposes of judicial review.
Tr. at 1-7. Thereafter, Plaintiff brought this action seeking
judicial review of the Commissioner's decision in a
complaint filed on March 16, 2018. [ECF No. 1].
Plaintiff's Medical History
March 18, 2013, Plaintiff presented to Amanda McFann, NP
(“Ms. McFann”), at Pain Specialists of
Charleston, P.A. (“Pain Specialists”), for low
back pain. Tr. at 270. She stated her pain had returned in
January and had worsened two weeks prior. Id. Ms.
McFann observed Plaintiff appeared uncomfortable. Tr. at 271.
She assessed degeneration of lumbar or lumbosacral
intervertebral disc, prescribed Nucynta Extended Release
(“ER”) 100 mg tablets, refilled Nucynta Immediate
Release (“IR”) 100 mg tablets for breakthrough
pain, and referred Plaintiff for magnetic resonance imaging
presented to Crystal Gutierrez, PA-C (“Ms.
Gutierrez”), at Pain Specialists on April 15, 2013. Tr.
at 272. She reported little relief from Nucynta. Id.
She complained of radiating back pain to her bilateral legs
and hips with occasional leg numbness, as well as radiating
neck pain to her shoulders, arms, and collarbone.
Id. Plaintiff indicated she had failed to follow up
for an MRI. Id. Ms. McFann discontinued Nucynta IR
and Nucynta ER and prescribed Neurontin 100 mg, Opana IR 10
mg, and Opana ER 10 mg. Id.
was hospitalized at the Medical University of South Carolina
(“MUSC”) on April 27, 2013, following a motor
vehicle collision. Tr. at 452. She was diagnosed with right
frontal hematoma, concussion, left hand abrasion, and
fractures of the right distal fibula, talus, calcaneus, and
navicular bone. Tr. at 460. On May 3, 2013, she underwent
open reduction and internal fixation of the right talus and
closed treatment of the right lateral malleolus. Tr. at 457.
Plaintiff was discharged on May 5, 2013. Tr. at 459.
followed up with Edward M. Tavel, M.D. (“Dr.
Tavel”), at Pain Specialists on June 24, 2013. Tr. at
276. She reported increased neck and back pain because of the
collision. Id. She indicated Opana ER was providing
only 20 percent pain relief. Id. Dr. Tavel
discontinued Opana ER 10 mg and Opana IR 10 mg and restarted
Nucynta ER 100 mg and Nucynta IR 100 mg. Id.
Plaintiff failed to show for a scheduled follow up visit on
July 22, 2013. Tr. at 278.
August 27, 2013, Plaintiff presented to her primary care
physician, Richard Ellis, M.D. (“Dr. Ellis”), for
anemia, headaches, myalgia, malaise, and fatigue. Tr. at 306.
Dr. Ellis noted no abnormalities on physical examination. Tr.
at 306-07. He prescribed Nucynta 100 mg and Adipex-P 37.5 mg.
Tr. at 307.
followed up at Pain Specialists on October 22, 2013. Tr. at
279. She reported minimal pain relief and requested an
increased dose of Nucynta ER. Id. Plaintiff
complained of continued pain in her neck and low back.
Id. She endorsed headaches, but denied tingling,
numbness, and weakness in her arms. Id. She
described her low back pain as radiating to her tailbone,
bilateral hips, and legs. Id. Ms. McFann
discontinued Nucynta ER 100 mg and prescribed Butrans Patch
20 mcg/hr. Tr. at 280. She again referred Plaintiff for an
MRI of the lumbar spine. Id.
October 31, 2013, an MRI showed a prominent right eccentric
bulge with facet degeneration resulting in moderately severe
canal stenosis and moderate bilateral foraminal narrowing at
the L4-5 level of Plaintiff's spine. Tr. at 296. It
further indicated a bulge and facet degeneration with
moderate canal stenosis and mild-to-moderate bilateral
foraminal narrowing at the L3-4 level. Id.
followed up with Ms. McFann on November 21, 2013. Tr. at 282.
She complained of constipation and reported minimal relief
with the Butrans Patch. Id. Plaintiff endorsed
muscle cramps, tingling, numbness, poor balance, and weakness
in her arms and legs. Id. She also complained of
pain, swelling, and stiffness in her joints. Id. Ms.
McFann refilled Plaintiff's medications and added
Cymbalta 30 mg for musculoskeletal pain. Tr. at 283. She also
recommended that Plaintiff follow up for a lumbar epidural
steroid injection (“LESI”) at ¶ 4-5.
December 9, 2013, an MRI of Plaintiff's brain showed a
few scattered, nonspecific periventricular/subcortical white
matter T2 hyperintensities. Tr. at 367-68. The radiologist
considered this to be indicative of migraine, prior
infection, history of trauma, or small vessel disease. Tr. at
368. The MRI further indicated a prominent supraclinoid
portion of the right internal carotid artery
(“ICA”). Id. The radiologist could not
exclude aneurysm and referred Plaintiff for additional tests.
Id. Plaintiff's physician subsequently diagnosed
bilateral brain aneurysm. Tr. at 371. Plaintiff underwent
right aneurysm coil embolization in December 2013 and
pipeline embolization of a left ophthalmic ICA aneurysm on
May 7, 2014. Id.
January 2, 2014, Plaintiff endorsed headaches. Tr. at 303.
Dr. Ellis observed no abnormalities on physical examination.
Tr. at 304. He assessed benign essential hypertension and
nonruptured cerebral aneurysm. Id.
March 10, 2014, Plaintiff requested Dr. Tavel increase
Nucynta and discontinue Cymbalta and Butrans Patch. Tr. at
287. Dr. Tavel recommended LESI, but Plaintiff rejected it.
Id. Dr. Tavel refilled Nucynta IR 100 mg and
referred Plaintiff to a cognitive therapist and a
was admitted to MUSC on March 25, 2014, for right
gastrocnemius recession, removal of hardware from talus,
great toe cheilectomy, arthrotomy for debridement of
tibiotalar joint, and subtalar ...