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Nelson v. Saul

United States District Court, D. South Carolina

July 3, 2019

Lynette L. Nelson, Plaintiff,
v.
Andrew M. Saul, [1] Commissioner of Social Security Administration, Defendant.

          REPORT AND RECOMMENDATION

          Shiva V. Hodges United States Magistrate Judge.

         This 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 affirmed.

         I. Relevant Background

         A. Procedural History

         On April 23, 2014, [2] 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].

         B. Plaintiff's Medical History[3]

         On 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 (“MRI”). Id.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         On 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.

         Plaintiff 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.

         On 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.

         Plaintiff 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. Id.

         On 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.

         On 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.

         On 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 rheumatologist. Id.

         Plaintiff 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 ...


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