So this is part 2 looking at actual results of ART cases since the October 3rd changes. As mentioned in part 1 a large number of these are closed with a successful agreement during the first 2 stages. Just over a quarter are rejected after ART. Some of these are access requests and some are just additions or alterations to current plans.
I am going to leave out the ones that are financial or family disputes (for example one where mother wanted to self managed childs plan but ex husband didn’t like not being consulted and initiated a review).
I am going to focus on the access and supports related ones. I am also going to leave out some of the super complex ones with multiple items applied for and varying outcomes on each point as they really need an article to themselves (one example that started on the 22nd of August 2022 that has only reached its conclusion 17th March 2025 Tsao and CEO, National Disability Insurance Agency (NDIS) [2025] ARTA 235 (17 March 2025)). I am going to focus more on losses than wins to help with understanding why certain things are not getting through. There are some that I will skip just because it becomes very obvious why it was not funded and we want to stick to the less obvious ones. For example:
Some are quite self explanatory.
Something you will see come up a lot in these cases is the six functional domains being used to determine whether funding and supports are needed. It is important when you are applying or asking for a review to reference these in your application and explain in detail how they are impacted by your condition and what supports you are seeking and how they will support the impairment. The link below goes into more detail on each of the six areas and how the scores work.
Important lessons to keep in mind (Thank you @Jessica for the amazing work behind a lot of this)
All decisions made are in view of the current rules. If you are going in hoping to use something that was approved prior to October 3rd as your evidence, you are not going to have a good time.
You can only request supports that relate to the impairments under which you were granted access to the scheme. For example, if you have back pain but you are on the scheme for blindness, you can’t ask for physiotherapy to be funded to help your back pain.
Use prior hearings to bolster arguments. If you go through the list and can find prior hearings with similar circumstances you can add them to your evidence. There are already 2 cases of Ipads being funded for communication purposes even though they are on the no list. They are now classified as replacement supports but considering they are being seen as reasonable and necessary enough to replace, I am guessing eventually enough cases will lead to them being back on the yes list.
Always show value for money. Get up to date quotes. Compare it to long term costs of other options like support workers. Show that long term this is going to be the more financially sound option.
Evidence is important. Make sure it is good quality. Make sure it is related to your funded disability. Make sure it is reasonably to expect that amount of hours. Make sure it is clear all medical and treatment options have been exhausted. Show proof of these, dates, sessions, practitioner names, notes.
On to some ART results
Let’s start with some cases where participants won.
Case 1
- 9 year old – level 2 ASD, ADHD, ODD and chromosomal deletion. Both parents and older brother all NDIS participants as well – requesting additional OT, speech therapy and support worker assistance.
- NDIA argued that the request was not evidence based and tried to claim the fact that they did many of the appointments via telehealth was proof more was not reasonable or necessary.
- Tribunal decided therapy weekly rather than fortnightly was more appropriate and that increasing support worker hours due to the family situation represented value for money based on the evidence the parents provided of the reduced capacity to do activities out in the community including attending appointments. Parents should not be penalised for the telehealth appointments when they themselves are impaired.
Case 2
- 40 year old with rheumatoid arthritis – requesting access to NDIS support.
- NDIA decided she was not eligible, a RORD was completed and they upheld that decision.
- ART reviewed the evidence and determined that she was eligible and overturned the decision by the NDIA because she proved that her functional capacity was significantly impacted in more than one category.
Case 3
- 10 year old – autism and severe intellectual disability – AR requesting 35 hours a week of support worker, 12 hours of respite, BST, OT, Speech and physio. An Ipad with a subscription to proloquo2go, swimming lessons. Also wanted to be plan managed not agency managed.
- Ipad and subscription approved as replacement supports, 90 hours of specialist behaviour intervention support, 12 hours of support worker services per week to assist with attending swimming lessons but no funding to pay for swimming lessons, speech path and OT approved. Refused to change from agency managed to plan managed as the agency felt that the participant was at risk of being taken advantage of.
Case 4
- 51 – ABI, legal blindness and other complications. NDIS approved SIL and SDA even though they were not applied for as family requested home modifications and 24 hour 1:1 supports in the home with inactive overnights. The family intended to keep the participant in the home and the brother had already agreed to take over support once the parents were too old.
- NDIA argued home modifications not necessary as there was not enough evidence or quotes and parents and brother provide informal supports 24 hours so workers were not needed.
- The tribunal consulted expert witnesses and concluded that home modifications as it was proven to be better value for money than SDA/SIL long term care. They also approved 24 hour 1:1 supports were reasonable and necessary based on their expert opinions as it was unreasonable to expect informal supports to provide 24 hour care.
Case 5
- 42 year old – SCN, COPD and fibromyalgia – requesting access.
- NDIA originally determined that the functional capacity was not significantly reduced.
- After review, the tribunal decided that the functional capacity was significantly reduced across mobility, self care and social and economic participation based on evidence provided. Access granted.
Case 6
- 44 year old- CED, PFD and other complications- requesting access to NDIS
- NDIA denied claiming the evidence was not sufficient.
- At tribunal, more evidence was requested. It was decided that the condition is not only permanent but also likely to deteriorate and the impairment is significant. Access granted.
Case 7
- 46 year old – foot deformity and CRPS with neuropathy – seeking access to NDIS.
- NDIA determined that a foot deformity did not meet access needs an that treatment options for the neuropathy were not exhausted.
- Tribunal decided there was significant impact on her functional capacity in multiple hours due to her movement limitations and allowed access.
Case 8
- 59 year old – vision and hearing impairment- requesting a mobility scooter (blazer) or alternative.
- NDIA argued that it was not reasonable or necessary as participant can take the bus.
- Tribunal decided that since participant lives in small rural town where buses are infrequent and unreliable that they should have access to a scooter to get to town and back independently and that this would be better value for money than bus passes, support workers and taxis.
As you can see from the above cases most were won either based on value for money or meeting the criteria for multiple functional domains to have been impacted and relating it back to the disability that they were trying to get funded or had already been funded for. With genuine claims getting this kind of evidence is key to improving your chances in these meetings.
Now you will see the difference when it comes to cases that were not resolved in favour of the participant.
Case 1
- 6 year old- autism level 3 - AR requesting to have the therapy access increased from 10 hours a week to 20 hours.
- NDIA and the tribunal decided this was not reasonable or necessary after looking at the research for the therapy indicating that more hours don’t lead to better outcomes. It was not seen as value for money either. This one was quite straight forward as to why the funding remained unchanged. Especially when you consider what 10 hours of therapy a week looks like for a small child.
Case 2
- 50 year old – spinal cord injury, Ehlers-Danlos, Psychosocial - requesting gym membership, a bum bag, lumbar pillow, brooks glycerin runners, voice activated software, sex worker services, equine therapy, assistance animal training for her rottweiler, and travel and accommodation in USA for medical treatment.
- In order, funded for exercise physiology sessions rather than gym membership, one is an approved therapy and one is an every day expense. The bumbag, pillow, shoes and software were a hard no because of the new legislation, but they did get funding for custom foot orthotics as a need did exist related to their disability. Definite no to a sex worker but they did get 12 hours of sex therapy to counsel them going forward. No to the equine therapy because the way the therapist described it, it sounded more like a recreational activity than a legitimate therapy run by a registered therapist in the evidence. They did not outright say not to the dog, but allocated 20 hours for an OT to assess for assistive technology reports for an assistance dog to see if it was able to be supported by evidence. The important thing in this case was that even though the specific things asked for did not meet the new legislation guidelines, both the tribunal and NDIA were willing to look at fundable alternatives with the participant. If you have something that you feel may be a no, having a close alternative to suggest may get you a more positive outcome. As for the treatment in the USA, NDIS does not cover treatment, or overseas trips to seek it.
Case 3
- 41 year old – type 1 diabetes, coronary heart disease, PTSD and a range of other issues relating back to morbid obesity – requested increased support worker hours from 10 hours a day to 20 and add 7 hours of nursing a day.
- NDIA decided based on evidence that the 10 hours a day was sufficient and did not change the plan that was already in place.
- Tribunal decided that participant did not even need the 10 hours a day based on the evidence they supplied. The tribunal reduced them to 5 hours a day of support work. They cited the participant providing false and misleading information and contaminating expert evidence. Participant was asked to submit to impartial medical examinations to get fresh evidence and refused. It is important when asked to submit evidence or attend medical assessments as part of the tribunal process that you seriously consider it. Refusal to participate in the process can lead to plan funding reductions or even removal from eligibility. There are some cases where we have seen NDIA request reviews from irrelevant medical practitioners to try and muddy the water, but where the request is reasonable, it can only provide more evidence for your case.
Case 4
- Applicant applying for Sjorgrens syndrome, SLE and HLH – Requesting support.
- Both NDIA and Tribunal agreed that most of the issues related back to autoimmune conditions and untreated fibromyalgia. As there were medical management plans and all treatment options had not been exhausted, they were denied. If you or someone else intends to have a disability funded, I try to recommend at least 2 years of “exhausting all medical and therapy options to manage the condition”. This gives you a paper trail, evidence of permanence, evidence of impairments significant enough to continue to seek treatments and a letter with all of that in a timeline to neatly give to the NDIA. NDIA will not assist if you are purposely avoiding or resisting treatment options before applying. They don’t see it as value for money to give funding for therapies and supports to people who show a history of being non compliant with therapies and supports.
Case 5
- 67 year old (64 when they applied) – chronic fatigue and tongue cancer – requesting access.
- Both tribunal and NDIA agreed this did not meet the requirements and that the aged care system was better suited. Medical conditions in general cannot be covered and will often be redirected to other more appropriate supports.
Case 6
- 43 year old – idiopathic hypersomnia – requesting access.
- Denied as functional capacity was not substantially reduced in any of the domains. The applicant did state that they have a small child and that their condition made taking care of them more difficult but this was not supported by any assessments from medical professionals or allied health supports. The applicant also stated they could do all tasks in each domain of functional capacity. If you can already do all of the tasks in each domain without assistance, NDIS may not be the right support network for you.
Case 7
- 12 year old – API, quadriplegic cerebral palsy and other complex issues – requesting 267 hours/year of conductive education therapy as it was funded previously until the legislation changes.
- Both NDIA and tribunal concluded that there was not enough evidence of effectiveness after consultation with medical and OT experts. If therapies are new, unregulated or controversial, as a participant, you have a much more difficult burden of proof to overcome. It is not impossible, but with the way the legislation is written now, there is very little wiggle room to try to get alternate therapies approved.
Case 8
- Participant experiencing significant deterioration due to aging, multiple complex needs. Medically permanent issues – requesting access to early intervention.
- After reviewing functional capacity in all key areas it was determined that none met eligibility as they were not substantially reduced. It was also determined that many of the issues were not new but were progressing so they do not meet the definition of early intervention. If you have something that has been happening for a long time, try to avoid using the terms early intervention or having NDIA use them because there is a good chance your claim may be denied on the same basis as this case.
Case 9
- 15 year old ASD level 3 – AR requesting foam filled bean bag, weighted blanket, vitamins and supplements, nutrition and feeding therapy.
- Tribunal decided all the consumables were every day items and not NDIS supports based on the new legislation. It also decided the NDIS plan to have a qualified responsive feeding therapist working with the participant and providing food exposure therapy was more cost effective than what was requested regarding vitamins, supplements and nutrition therapy. Vitamins and supplements are not NDIS supports and are considered every day use items unless they are specific to a disability with a feeding issue.
Case 10
- 10 year old ASD level 2- AR requesting Anat Baniel Method therapy on top of other therapies.
- Both NDIA and tribunal concluded that the literature provided as evidence did not support the conclusion that ABM was effective for ASD and was denied. This was again a case of the therapy needing to meet a higher level of proof in order to pass.
Case 11
- 67 year old BPD and PTSD as well as other complications – requesting $20,000 of art supplies as funded supports. He claimed he had been doing so for years when he was actually calling it art therapy and submitting invoices under core funding.
- As it is not assistive and is a lifestyle item, not a therapy, and the participant could not provide an invoice or itemised list of what the money would be spent on, the request was denied. The participant was also warned regarding misuse of funds. With the new legislation it is much more clear what you cannot spend funding on. Just because something worked before, does not mean it will now. Invoices for very specific requests as part of your evidence are also important. They could mean the difference between something being considered and the tribunal just denying it from the start.
Case 12
- 29 year old suffering neurological disorder resulting in 30-100 seizures a day – requesting extra funding for an assistance animal, solar panels and a massage recliner.
- The assistance animal was not seen as value for money because it did not reduce other supports or replace them, this would be doubling up. The participant also could not explain what areas it was to improve regarding their disability related impairments. Solar panels are an every day item and were refused. The massage chair was an interesting one. The NDIA determined they could get a chair if they trialed suggested chairs from an OT, the participant refused the trial so the claim was denied. I am assuming there was a specific chair they wanted but it was not an approved option or disability specific which is why the OT assessment was offered as an option.
Claim 13
- 35 year old – PTSD, MDD, BPD and tourettes – seeking 24 hour support worker, new air conditioner, STA tour costs, Brain therapy and nursing for catheter management be added to her plan that already had 9 hours a day of support worker assistance self care and 3 hours a day community access.
- All were deemed neither reasonable or necessary except the nursing care as the participant needed to rely on a catheter so nursing met the requirements for catheter management. I am waiting to see more information regarding things like air conditioners and white goods. There are a small number of cases where, without these items, the participant is at serious risk due to their impairments. Over time I think we will see the new legislation change in order to accommodate this in some way but it will take some time.
Case 14
- 62 year old – stroke after heart attack – requesting access.
- While he is impaired and those impairments are permanent, not all medical and therapy options had been explored and it was also determined that he was not significantly impaired in any of the six domains and was denied based on these two points.
Case 15
- 61 year old rheumatoid arthritis – seeking access
- While it was determined to be permanent and they are impaired, there was no considerable evidence that any of the six domains were substantially affected. In order to be eligible there would need to be more evidence based on one or all domains showing that they have reached a level of impairment to be considered.
Case 16
- 36 year old – untreated fibromyalgia, addisons disease, depressive disorder, PVNS and POTS – seeking access
- As many of the conditions have medical treatment options that she has openly refused to engage with, she does not meet the access requirements of having exhausted all options. In order to change this she would need to engage with the practitioners offering treatment and consistently show evidence of therapies and treatments being used and failing before applying again.
Case 17
- 32 year old with work place injury currently under workers compensation benefits.
- While the tribunal and NDIA agreed the injury was permanent, not all treatment and surgical options had been explored and so they do not meet the eligibility criteria. They were also still engaging with work cover at the time and was still in the process of determining the full extent of the injury. This process would need to be completed to be considered for NDIS in future and I think based on the injury that they may qualify in future. Remember you can apply as many times as you need to, it is just a slow process to navigate.
Case 18
- 42 year old – psychosocial living alone in public housing- seeking to increase her transport funding from level 1 to level 3 to aid looking for work and study, wanting 28 days of respite funding STA.
- During the review it came to light that the participant was not looking for work or study and just wanted extra funding to go to recreational activities and that they believed STA was for them to be able to go on vacation with a support worker to new locations which is not what STA is for. She lives alone so there is no need for respite care either. Both requests were denied as not reasonable or necessary. It is important going into these things that we have reasonable expectations and an understanding of what the NDIS is really for. There are some people who are disappointed with their experiences based solely on the reality not meeting their expectations. That is also part of why I feel it is important to look over these case notes. If you have a realistic expectation of what you are walking into, you can better prepare.
Case 19
- 21 year old – intellectual impairment – wanted supplements funded.
- Supplements are not NDIS supports unless disability related (for example PIC feeding food supplementation) and so the request was denied. I have seen a few people who have read the legislation, read outdated information on the NDIS site itself, then read old blogs from before the changes or old ART cases, who have then become either very confused or very convinced about whether something is allowed or not. The legislation is what is going to be used to base decisions on. It is the tribunals job to be fair but also to make sure that is upheld.
Case 20
- 62 year old – on NDIS for Psychosocial disorder and secondary physical disorder. The original NDIA decision funded a $195,532 plan. They requested additional funding for light and easy and a complex bathroom renovation.
- Tribunal decided the $5269 for meals already in the plan was sufficient for one person but made NDIA state it in the plan instead of having it come from flexible funding. The bathroom renovation was not seen as reasonable or necessary for the disability that was funded. The renovations were not sufficiently supported in relation to how they impacted the funded impairments. Without this evidence the tribunal could not even consider it.
Case 21
- Participant requesting naturotherapy, naturopathic herbal tonics and supplements, 1:1 yoga sessions and art therapy.
- Tribunal stated that according to the back on track amendments, none of these items were fundable except the art therapy. The Participant was asked 4 times to provide any evidence of how this would support their disability and never supplied any, so this was also dismissed. The tribunal will try to give you every opportunity to supply your evidence and can be very lenient if you communicate well. But you need to supply evidence at some point to support your claim.
Claim 22
- 12 year old – ASD, Ehlers-danlos syndrome, ADHD and other complications – AR requesting $4560 for cannabis oil
- Tribunal stated even when prescribed, that this is a day to day living cost and denied the claim. Medications, treatments and surgery are all considered the responsibility of the health system. NDIS will not cover these costs in any way because they are already subsidised by another existing government agency.
Claim 23
- 56 year old – fibromyalgia, spinal degeneration, major depression – seeking access
- Openly told the tribunal that they had no impairments in any of the six categories and that they could go out and interact with others but choose not to. Tribunal had no choice but to deny the claim. I feel like either the applicant did not have an understanding of what NDIS was for or did not understand the requirements to meet eligibility. Either way their own comments strongly influenced the outcome in this case.
Claim 24
- 67 year old (64 at time of application) applied based on psychosocial disability complications. Seeking access.
- They did not complete any courses of treatments, kept dropping out of programs that NDIA stated would help her improve her impairments. During tribunal it came to light that woman and daughter had already applied for aged care and were aware that she had been accepted but were under the impression that they could get more from NDIS. Under the legislation a person can not be funded under 2 schemes so claim is automatically declined and the applicant was told to use the aged care funding they were approved for.
Claim 25
- 11 year old – multiple associated medical conditions leading to impairment – AR applying for $90,000 in outstanding invoices from overspend on previous plan. Family wanted far more supports than original plan allowed. Father was an accountant and knew there would be an overspend and expected a “top up”.
- Tribunal denied all outstanding invoices as evidence of a spreadsheet was found showing the parents were well aware of the projected over expenditure. Providers were obviously significantly impacted by this decision as well. There has been a trend with participants running out of funding and, out of desperation, telling supports to continue working. This places a lot of risk on the workers because now there is a much higher chance of denial of back pay. Many providers have been buried by debts they incurred doing this. It puts your providers in a hard spot as well. They stay and risk financial distress or they leave and risk the participant finding another provider when funding starts again due to their “disloyalty”. It definitely puts participants in a precarious place, it is not an easy issue to go through. On top of that, because of so many issues, many providers are now including participants being held financially accountable for debts in their service agreements. Debt collectors will enforce these debts if their services are engaged by providers. The best case scenarios in these circumstances is that NDIA sees that the participant is without support and rushes a COC or review but this has also caused some participants to lose funding in their urgent need to get a plan approved. Best practice is to not run out of funding but we also do not live in a perfect world.
That will do for this article I think. There is a clear pattern of what is needed in order to have a successful ART process but meeting all of the requirements is not always straight forward. NDIA is also sometimes not clear on what they are asking for. The important thing is to make sure you have collected everything you can ready to be supplied as evidence and to keep your requests reasonable so they are taken more seriously.
As always, if you would like further information or have questions, feel free to reach out.