Cox and National Disability Insurance Agency

The Administrative Appeals Tribunal considered the dispute between Mr. Cox and the National Disability Insurance Agency (NDIA) concerning the NDIA's refusal to fund Botox treatment for Mr. Cox, who has quadriplegia. The core of the disagreement was whether this treatment constituted a "reasonable and necessary" support under the National Disability Insurance Scheme.

The Tribunal was required to determine two primary legal issues: first, whether the proposed Botox treatment for Mr. Cox's spasticity and associated pain was a reasonable and necessary support within the meaning of the *National Disability Insurance Scheme Act 2013* (Cth); and second, whether the NDIA's decision to refuse funding for this support was consistent with the relevant provisions of the Act and associated policy. The Tribunal also had to consider whether any functional improvements derived from the treatment were incidental to its primary purpose of pain management.

In reaching its decision, the Tribunal applied the criteria for "reasonable and necessary" supports as set out in section 34 of the Act. It found that while the Botox treatment might offer some incidental functional benefits, its primary purpose and likely outcome was pain management. The Tribunal concluded that the evidence did not establish that the pain experienced by Mr. Cox was of a severity or nature that would justify funding the Botox treatment as a reasonable and necessary support under the NDIS, particularly when considering alternative pain management strategies. Consequently, the Tribunal affirmed the NDIA's decision.