Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_12-cv-00357/USCOURTS-alsd-1_12-cv-00357-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

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1

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

MELISSA E. BROOM, :

 :

Plaintiff, :

 :

vs. : CIVIL ACTION 12-0357-M

 :

MICHAEL J. ASTRUE, :

Commissioner of Social Security,:

 :

Defendant. :

MEMORANDUM OPINION AND ORDER

In this action under 42 U.S.C. § 1383(c)(3), Plaintiff 

seeks judicial review of an adverse social security ruling which 

denied a claim for Supplemental Security Income (hereinafter 

SSI) (Docs. 1, 13). The parties filed written consent and this 

action has been referred to the undersigned Magistrate Judge to 

conduct all proceedings and order the entry of judgment in 

accordance with 28 U.S.C. § 636(c) and Fed.R.Civ.P. 73 (see Doc. 

20). Oral argument was waived in this action. Upon 

consideration of the administrative record and the memoranda of 

the parties, it is ORDERED that the decision of the Commissioner 

be AFFIRMED and that this action be DISMISSED. 

This Court is not free to reweigh the evidence or 

substitute its judgment for that of the Secretary of Health and 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 1 of 15
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Human Services, Bloodsworth v. Heckler, 703 F.2d 1233, 1239 

(11th Cir. 1983), which must be supported by substantial 

evidence. Richardson v. Perales, 402 U.S. 389, 401 (1971). The 

substantial evidence test requires "that the decision under 

review be supported by evidence sufficient to justify a 

reasoning mind in accepting it; it is more than a scintilla, but 

less than a preponderance." Brady v. Heckler, 724 F.2d 914, 918 

(11th Cir. 1984), quoting Jones v. Schweiker, 551 F.Supp. 205 

(D. Md. 1982).

At the time of the administrative hearing, Plaintiff was 

twenty-eight years old, had completed a high school education1

(Tr. 58), and had no relevant previous work experience (see Tr. 

47). In claiming benefits, Plaintiff alleges disability due to 

a right humerus fracture status post open reduction internal 

fixation (ORIF) and borderline personality disorder (Doc. 13 

Fact Sheet).

The Plaintiff filed an application for SSI on February 1, 

2010 (Tr. 128-31l; see also Tr. 29). Benefits were denied 

following a hearing by an Administrative Law Judge (ALJ) who 

determined that although Broom had no relevant past work 

experience, there were jobs which she could perform (Tr. 29-49). 

 1

Error! Main Document Only.Plaintiff testified that she had received 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 2 of 15
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Plaintiff requested review of the hearing decision (Tr. 22-23) 

by the Appeals Council, but it was denied (Tr. 1-6).

Plaintiff claims that the opinion of the ALJ is not 

supported by substantial evidence. Specifically, Broom alleges 

the single claim that she is not capable of performing medium 

range work (Doc. 13). Defendant has responded to—and denies—

this claim (Doc. 15). The relevant evidence of record follows.2

Records from Springhill Medical Center show that Broom was 

admitted on January 4, 2010 for sixteen days for what appeared 

to be a suicide attempt, heavily influenced by alcohol, in which 

she jumped from a 20-30 foot overpass (Tr. 230-37). Injuries 

were as follows: a right humeral fracture; fractures of the 

T12, L1, L2, L3, and L4; a grade III-IV liver fracture with 

hemoperitoneum; and a right renal fracture laceration. During 

the first several days, Plaintiff developed severe psychosis to 

the extent that she was disoriented in three spheres and 

confused for which she received psychiatric intervention. Broom 

also underwent an ORIF of the right humerus and primary repair 

of the pectoralis tendon to the bone while hospitalized. 

On April 20, 2010, Plaintiff was consultatively examined by 

 a Graduate Equivalency Degree (Tr. 40). 2

Plaintiff asserts disability as of January 1, 2010 (Tr. 128), so 

the Court will not review evidence generated more than a year prior to 

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Dr. Henrietta T. Kovacs who noted complaints of pain in the 

right arm and right shoulder, pain in the tailbone and thighs, 

and insomnia; Broom was alert, oriented, and in no distress (Tr. 

238-44). The doctor noted that Plaintiff had full range of 

motion (hereinafter ROM) in the right shoulder, though she 

complained of pain radiating into her neck. Kovacs performed 

ROM analysis, noting no limitations in the cervical spine, 

shoulders, elbows and forearms, knees, ankles, or wrists; though 

she could only flex her dorsolumbar spine 75o (out of 90o), 

other measurements were within normal limits. No measurements 

were taken of the hips. The doctor’s impression was as follows: 

(1) possible polycystic ovarian syndrome but her history is more 

indicative of dysmenorrhea or endometriosis; (2) right shoulder 

and arm pain status post open reduction and internal fixation of 

compound fracture of right humerus; (3) coccygodnia; (4) 

borderline personality disorder; (5) low back pain in flexion; 

(6) history of ETOH and tobacco abuse; and (7) strange gait.3

On April 29, 2010, Psychologist John W. Davis examined 

Plaintiff, noting no unusual gait or posture abnormalities (Tr. 

 that date. Other current evidence not considered relevant to the 

particular claim raised will, likewise, not be reviewed herein. 3

Kovacs stated that “[p]atient had 2 to 3 steps normal then she 

was limping by not bending the right knee and the right hip properly, 

then again she had a few normal steps and then the limping with the 

failure of bending the hip and knee properly. I cannot fathom what 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 4 of 15
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245-49). Conversation was normal; Broom showed some anxiety and 

depression but displayed the capacity for a full range of 

emotional qualities. Plaintiff’s mood was generally one of 

agitated depression, though she seemed to have the capacity for 

a positive affect; Broom was oriented in three spheres. There 

were no loose associations, tangential or circumstantial 

thinking, or confusion; judgment and insight were considered to 

be impaired. Plaintiff was thought to be of low average 

intelligence; she “exhibited symptoms consistent with Borderline 

personality disorder as evidenced by anger, dramatics, 

manipulation, victim mentality, [and] self-centered[ness]” (Tr. 

248). Davis’s diagnosis impression was severe borderline 

personality disorder with a guarded prognosis, noting that it 

was “reasonable to expect a favorable response to treatment 

within a year or two” (Tr. 248). The Psychologist thought that 

Broom had the following restrictions:

The claimant’s ability to understand 

and remember simple instructions, carry out 

simple instructions, and make judgments on 

simple work-related decisions is mildly 

impaired.

The claimant’s ability to understand 

and remember complex instructions, carry out 

complex instructions, and make judgments on 

complex work-related decisions is moderately 

 could cause such a strange walking pattern” (Tr. 241).

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 5 of 15
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impaired.

The claimant’s ability to interact 

appropriately with the public, interact 

appropriately with supervisors and interact 

appropriately with co-workers, respond

appropriately to usual work situations and 

to changes in routine setting is presently 

markedly impaired, but should improve.

The claimant cannot manage any benefits 

that are forthcoming due to poor judgment.

(Tr. 248-49). 

On April 30, 2010, a non-examining “State agency 

psychological consultant” (Tr. 43), M. Hope Jackson, Ph.D., 

completed a psychiatric review technique form, based on the 

evidence of record as of that time, in which she indicated that 

Plaintiff had a borderline personality disorder (Tr. 251-63). 

Jackson indicated that Broom had mild restriction of activities 

of daily living, moderate difficulties in maintaining social 

functioning, moderate difficulties in maintaining concentration, 

persistence, or pace, but had had no episodes of decompensation 

(Tr. 260). The Non-examiner also completed a mental residual 

functional capacity (hereinafter RFC) assessment in which she 

indicated that Plaintiff would be moderately limited in her 

ability to do the following: understand, remember, and carry 

out detailed instructions; maintain attention and concentration 

for extended periods; interact appropriately with the general 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 6 of 15
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public; accept instructions and respond appropriately to 

criticism from supervisors; get along with coworkers or peers 

without distracting them or exhibiting behavioral extremes; and 

respond appropriately to changes in the work setting (Tr. 264-

67). Jackson also offered the following conclusions:

[] Claimant has the ability to 

understand, remember, and carry out very 

short, simple instructions. She can pay 

attention for 2 hour periods.

[] Contact with the general public and 

coworkers should be limited in the 

workplace. Supervision and feedback should 

be presented tactfully and in a nonconfrontational manner.

[] Changes in the workplace should be 

infrequent.

(Tr. 266). 

On June 23, 2010, Dr. E. Russell March, Jr., a nonexamining physician with the Social Security Administration, 

completed a physical RFC assessment in which he indicated that 

Broom was capable of lifting and carrying up to fifty pounds 

occasionally and twenty-five pounds occasionally (Tr. 268-75). 

Plaintiff would also be able to stand or walk for six hours in 

an eight-hour day; she would, however, be limited in her ability 

to use hand controls. Although Broom would never be able to 

climb ladders, she could climb stairs occasionally; she would be 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 7 of 15
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able to balance, stoop, kneel, crouch, and crawl frequently, 

however. She would also be limited in her ability to reach in 

all directions, including overhead; Plaintiff should also avoid 

working around machinery and at heights.

Treatment records from Altapointe Health Systems show that, 

on January 27, 2010, Broom was diagnosed with severe, recurrent, 

major depressive disorder, alcohol abuse, and borderline 

personality disorder (Tr. 340; see generally Tr. 276-345). Her 

GAF rating at that time was 51.4 On February 8, Plaintiff began 

individual therapy sessions (Tr. 336). In one of those sessions 

a month later, Broom talked of her alcohol dependence and 

problem with night terrors; the therapist noted the 

discrepancies between her words and actions (Tr. 333-34). On 

March 23, Plaintiff was described as euthymic; she complained of 

tiredness and not sleeping well at night with the Trazodone5

which increased nightmares and leg cramps (Tr. 328-29). The 

Trazodone was discontinued, the Effexor6 continued, and a sleep 

 4

Error! Main Document Only.“A GAF score between 51-60 indicates 

“moderate symptoms (e.g., flat affect and circumstantial speech, 

occasional panic attacks) or moderate difficulty in social, 

occupational or school functioning (e.g., few friends, conflicts with 

peers or co-work).” American Psychiatric Association, Diagnostic and 

Statistical Manual of Mental Disorders, 32 (4th ed. 1994). 

5

Error! Main Document Only.Trazodone is used for the treatment of 

depression. Physician's Desk Reference 518 (52nd ed. 1998).

6

Error! Main Document Only.Effexor is used “for the treatment of 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 8 of 15
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medication was prescribed. In a therapy session on March 29, 

2010, Broom discussed her “need” to fix other people rather than 

focusing on her own problems (Tr. 323-24); two weeks later, the 

therapist discussed Plaintiff’s failure to attend all of her 

therapy sessions and obtained Plaintiff’s renewed commitment to

treatment (Tr. 317-18). On April 20, Broom expressed anxiety 

due to an anticipated massage therapy national exam; it was 

noted that she had limited insight into her alcohol use (Tr. 

315-16). Following a therapy session nine days later, Plaintiff 

was noted to have a mildly elevated mood and only fair insight 

and judgment (Tr. 312-13). On May 10, Broom stated that she had 

been a little depressed because of a breakup with her boyfriend; 

this also caused loss of sleep and an episode of intoxication 

(Tr. 309-10). On May 25, Plaintiff reported low energy, crying 

spells, and increased drinking because of her breakup; the 

therapist rated her insight as poor (Tr. 303-04). On June 8, 

Broom had reconciled with her boyfriend which improved her mood 

and sleep; the doctor rated her insight as fair, judgment as 

poor, and anxiety as mild (Tr. 301-02). On September 20, 

Plaintiff stated that she was taking her medications as 

prescribed and was doing well; she enjoyed daily activities and 

 depression. Physician's Desk Reference 3037 (52nd ed. 1998).

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reported no anxiety or thoughts of hopelessness or worthlessness 

though she still had nightmares two-to-three nights per week 

(Tr. 290-92). The next record of contact was on February 14, 

2011 which noted sadness; insight and judgment were considered 

to be good (Tr. 287-88; see also Tr. 285-86). On July 18, Broom 

stated that she had not been sleeping during the past week and 

felt exhausted, anxious, and stressed; it was noted that she 

seemed to be “making an effort to sound ‘unusual’” (Tr. 347; see 

generally Tr. 347-50). The RN characterized her insight as 

poor, judgment as fair, and anxiety as mild while the CNRP rated 

Broom’s insight and judgment as good with no anxiety. 

In her administrative decision, the ALJ reached the 

following conclusion regarding Broom’s ability to work:

[T]he undersigned finds that the claimant 

has the residual functional capacity to 

perform less than the full range of medium 

work as defined in 20 C.F.R. 416.967(c), in 

function by function terms (SSRs 83-10 and 

06-8p), with certain non-exertional 

restrictions associated with that level of 

exertion. The claimant’s specific physical 

capabilities during the period of 

adjudication have been the ability to 

lift/carry up to 50 pounds occasionally and 

25 pounds frequently; stand/walk with normal 

breaks for a total of 6 hours in an 8-hour 

workday; sit with normal breaks for a total 

of about 6 hours in an 8-hour workday; 

push/pull arm controls with the right upper

extremity occasionally, and push/pull arm 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 10 of 15
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controls with the left upper extremity with 

no limitation; climb ramps/stairs 

occasionally; balance, stoop, kneel, crouch 

and crawl frequently; perform overhead 

reaching with the right upper extremity 

occasionally, with no limitations in 

overhead reaching with the left upper 

extremity; push/pull leg controls with no 

limitations; handle, finger and feel 

bilaterally with no limitation; and work in 

a job that does not require her to be able 

to climb ladders, ropes or scaffolds. The 

claimant’s specific mental capabilities 

during the period of adjudication have been 

the ability to perform simple, routine, 

repetitive tasks (SRRTs); have brief, 

superficial contact with the public; have 

brief contact with co-workers and work 

independently, but could work in close 

proximity to coworkers; handle supervision 

given in a non-threatening manner; and adapt 

to minimal changes in the work setting.

(Tr. 34-35). In reaching this determination, the ALJ found that 

Broom’s testimony regarding her limitations was not credible 

(Tr. 36), a finding not challenged in this action (see Doc. 13). 

The ALJ noted that “the record does not contain any opinions 

from treating physicians indicating that the claimant is 

disabled or even has limitations greater than those determined 

in this decision” before going on to assign “great weight” to 

the opinions and conclusions of Dr. March and Psychologist 

Jackson (Tr. 46). This concludes the medical evidence.

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Plaintiff claims that the ALJ erred in finding that she is 

capable of performing medium range work. Broom asserts that she 

is not capable of performing either the physical or mental 

components of medium work (Doc. 13). “Medium work involves 

lifting no more than 50 pounds at a time with frequent lifting 

or carrying of objects weighing up to 25 pounds. If someone can 

do medium work, we determine that he or she can also do 

sedentary and light work.” 20 C.F.R. § 416.967(c) (2012). The 

Court notes that the ALJ is responsible for determining a 

claimant’s residual functional capacity (hereinafter RFC). 20 

C.F.R. § 416.946 (2012). 

In bringing this claim, the main thrust of Broom’s argument 

is that the ALJ relied on the opinions and conclusions of March 

and Jackson, neither of which examined her. Plaintiff has also 

provided the corollary argument that the ALJ’s acceptance of the 

conclusions of the physicians who actually examined her, viz., 

Davis and Kovacs, would have resulted in a less demanding 

residual functional capacity finding.

Psychologist Davis found Plaintiff markedly limited in her 

ability to interact appropriately with the public, supervisors, 

and co-workers and in her ability to respond appropriately to 

usual work situations as well as changes in those situations 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 12 of 15
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(Tr. 249). Davis suggested other lesser limitations as well 

(Tr. 248-49). The Court notes that the records from Altapointe 

Health Systems, over the one and one-half years relevant to this 

action, do not support the limitations suggested by Davis (Tr. 

276-345). Those records are more consistent with the 

conclusions of Psychologist Jackson regarding Broom’s abilities.

The Court would also note that the Altapointe records 

demonstrate Plaintiff’s failure to seek the treatment available 

to her as her sessions dwindled to, approximately, one every 

four months. The records demonstrate that she refused treatment 

(see Tr. 296, 317, 319, 321, 322, 325). The Social Security 

regulations state that “[i]n order to get benefits, you must 

follow treatment prescribed by your physician if this treatment 

can restore your ability to work.” 20 C.F.R. 416.930(a) (2012). 

The regulation goes on to state that “[i]f you do not follow the 

prescribed treatment without a good reason, we will not find you 

disabled or, if you are already receiving benefits, we will stop 

paying you benefits.” 20 C.F.R. § 416.930(b) (2012); see also 

Dawkins v. Bowen, 848 F.2d 1211, 1213 (11th Cir. 1988). Broom’s 

failure to seek treatment belies her claim for disability.

With regards to the physical RFC, Plaintiff admits that 

although Dr. Kovacs examined her, she did not provide an 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 13 of 15
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evaluation of her ability to perform work-related activities 

(Doc. 13, p. 10). What she does direct this Court’s attention 

to, however, is her telling the doctor that she had previously 

suffered a tailbone injury which caused problems for her with 

sitting (Doc. 13, p. 13; cf. Tr. 238). The coincidence of this 

communication with Dr. Kovacs, coupled with Dr. March’s failure 

to indicate how long he thought Broom could sit during an eighthour-day (see Tr. 269), forms the basis of Plaintiff’s argument 

that the ALJ incorrectly determined that she was capable of 

physically performing medium level work.

In reaching his determination that Dr. March’s conclusions 

were to be given great weight, the ALJ noted that Broom “has not 

sought treatment for her physical impairments since her release 

from the hospital in January 2010” (Tr. 46). The Court notes, 

with regard to her tailbone, that Broom declined a scheduled 

back x-ray to see if she had bone fragments in her vertebra; as 

such, no actual proof exists of the broken bone. Social 

security regulations state that Plaintiff is responsible for 

providing evidence from which the ALJ can make an RFC 

determination. 20 C.F.R. § 416.945(a)(3). Plaintiff’s mere 

assertion of an inability to sit, without objective medical 

Case 1:12-cv-00357-M Document 21 Filed 01/03/13 Page 14 of 15
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evidence, provides no basis for her argument that she cannot 

sustain the sitting requirements of medium exertion work.

Plaintiff has raised a single claim in bringing this 

action. The Court finds that the ALJ’s conclusions are 

supported by substantial evidence. Upon consideration of the 

entire record, the Court finds "such relevant evidence as a 

reasonable mind might accept as adequate to support a 

conclusion." Perales, 402 U.S. at 401. Therefore, it is 

ORDERED that the Secretary's decision be AFFIRMED, see 

Fortenberry v. Harris, 612 F.2d 947, 950 (5th Cir. 1980), and 

that this action be DISMISSED. Judgment will be entered by 

separate Order. 

DONE this 3rd day of January, 2013.

s/BERT W. MILLING, JR. 

UNITED STATES MAGISTRATE JUDGE

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