CKPN and National Disability Insurance Agency

The Administrative Appeals Tribunal considered a dispute between CKPN, a child participant in the National Disability Insurance Scheme, and the National Disability Insurance Agency (NDIA). The core of the disagreement concerned the approval of CKPN's Statement of Participant Supports (SOPS) under her NDIS plan, specifically regarding additional funding requested for allied health interventions and support worker assistance. CKPN has complex medical conditions including severe gastro-oesophageal reflux disease, a redundant length colon with poor gut motility, avoidant/restrictive food intake disorder, sensory processing issues, insomnia, anxiety, and chronic pain.

The Tribunal was required to determine whether the requested supports met the criteria of "reasonable and necessary supports" as defined by section 34(1) of the National Disability Insurance Scheme Act 2013 (Cth). This involved assessing the medical and clinical evidence presented regarding CKPN's various health issues and the proposed interventions. The Tribunal also considered the duration of the NDIS plan and the appropriate allocation of funding for different types of support.

In its reasoning, the Tribunal acknowledged the significant medical challenges faced by CKPN, as detailed by her treating paediatric gastroenterologist and other specialists. It found that most, but not all, of the requested supports met the "reasonable and necessary" criteria. Specifically, the Tribunal determined that while continued intensive treatment by a particular psychologist (P1) was not fully substantiated for ongoing funding due to limited evidence of efficacy, a limited period of 12 hours of P1's services would be funded to facilitate a structured handover to alternative supports. The Tribunal also noted the importance of a 12-month plan duration to support CKPN's transition to primary school and the development of her feeding strategies.

Ultimately, the Tribunal set aside the NDIA's decision and remitted the matter with a direction to facilitate the approval of a new SOPS for CKPN. The approved supports included specific hours for support worker assistance, paediatric psychiatrist and/or clinical psychologist services, psychological therapy and assessment by P1, speech pathology, occupational therapy, and clinical leadership by an allied health professional. The Tribunal also made non-binding observations regarding the relationship between CKPN's parents and the NDIA, suggesting a potential benefit in changing CKPN's case manager to foster a fresh start.