The clinical question driving this investigation was direct: Do patients with obstructive sleep apnea who fail to meet the Centers for Medicare and Medicaid Services (CMS) 90-day continuous positive airway pressure adherence threshold continue using therapy at one year? The bottom line, as summarized by the researchers, is that more than one-third of these initially nonadherent patients were still using CPAP at the one-year mark. Crucially, their average use was deemed sufficient to provide symptomatic relief, prompting a direct challenge to the prevailing notion that early nonadherence is a definitive predictor of long-term treatment failure.
Background: The Genesis of the 90-Day Adherence Rule
The Centers for Medicare and Medicaid Services (CMS), a federal agency administering Medicare and Medicaid, established a 90-day adherence requirement for CPAP therapy to ensure that Medicare beneficiaries were actively using the device to treat their obstructive sleep apnea. This policy, implemented to manage healthcare expenditures and ensure the efficacy of prescribed treatments, stipulated that beneficiaries must demonstrate a minimum level of CPAP usage within the initial three months of therapy to maintain continued coverage. The rationale was that if a patient was not consistently using the device during this critical early period, they were unlikely to benefit from it in the long term, and therefore, continued payment for the equipment and supplies would be unwarranted.
However, the specific evidence base supporting the 90-day benchmark has been a subject of ongoing discussion within the medical community. While the importance of consistent CPAP use for managing OSA and its associated health risks is well-established, the arbitrary nature of a fixed 90-day period has been questioned. Obstructive sleep apnea is a chronic condition that can significantly impact a patient’s quality of life, leading to excessive daytime sleepiness, impaired cognitive function, and an increased risk of cardiovascular disease, stroke, and other serious health complications. Effective management of OSA typically involves long-term, often lifelong, adherence to treatment.
Study Design and Methodology: A Real-World Examination
This study, conducted by researchers at Kaiser Permanente Southern California, a large, integrated healthcare system, adopted a retrospective observational cohort design. The investigation focused on adults diagnosed with obstructive sleep apnea who were prescribed CPAP therapy between January 1, 2020, and December 31, 2023. The key differentiating factor of this healthcare system, which is crucial to understanding the study’s implications, is its policy of continuing CPAP coverage for patients regardless of their adherence to the CMS 90-day threshold. This provided a unique environment to observe long-term usage patterns without the confounding variable of coverage withdrawal based on early nonadherence.
The study meticulously stratified patients into two groups: those who met the CMS 90-day adherence requirement and those who did not. Device usage was then evaluated specifically during the twelfth month of therapy, defined as the period between day 330 and day 360 after the initial treatment dispensation. This precise temporal focus allowed for a direct comparison of long-term usage between the two cohorts.
Synopsis of Findings: Challenging the Adherence Threshold
The comprehensive analysis encompassed a substantial cohort of 132,492 adults who had at least one recorded CPAP usage episode within the first year of receiving their device. The demographic profile of the study population reflected typical OSA patient characteristics: a mean age of 55.0 years, with a notable majority being male (65.5%). The severity of their OSA was quantified by the apnea-hypopnea index (AHI) using a 4% desaturation criterion, which averaged 32.5 events per hour, indicating a significant prevalence of moderate to severe sleep apnea within the cohort.
Within this large group, 49.0% of patients successfully met the CMS 90-day adherence requirement. This adherence rate was slightly higher among older individuals, with 53.5% of patients aged 65 years or older achieving the benchmark. Conversely, the study identified several factors associated with failure to meet the initial CMS threshold. These included younger age, female sex, non-white race or ethnicity, lower socioeconomic status, and less severe obstructive sleep apnea. These demographic and clinical characteristics may point to potential barriers to adherence that extend beyond simple patient motivation or the perceived efficacy of the therapy itself, such as access to education, support, or understanding of the condition.
The most striking findings emerged when examining the group of patients who did not meet the initial CMS threshold. Out of the 67,906 individuals in this category, a substantial 36.0% demonstrated continued CPAP use during the twelfth month of therapy. This figure directly contradicts the expectation that early nonadherence equates to complete abandonment. For these continued users, the average nightly usage was calculated at 197 minutes, and CPAP was utilized for at least four hours on an average of 42.9% of nights.
Further analysis revealed nuanced patterns of usage even among those who initially struggled. Approximately 20.9% of all patients who were initially CMS-nonadherent averaged at least two hours of CPAP use per night during month 12. A significant subset, 13.6%, averaged at least four hours of nightly use. These rates were even more pronounced in the older demographic, with 23.3% of nonadherent patients aged 65 or older averaging at least two hours, and 16.5% averaging at least four hours. These figures are particularly important because established clinical guidelines and expert consensus often consider four hours of use per night as a minimum threshold for achieving therapeutic benefit from CPAP.
Implications and Broader Impact: Rethinking Adherence Metrics
The findings of this study carry significant implications for how CPAP therapy adherence is understood and managed within the healthcare system, particularly concerning insurance coverage policies. The research directly challenges the assumption that a rigid 90-day adherence metric is a reliable indicator of long-term treatment success or failure. It suggests that a more dynamic and individualized approach is warranted.
One of the primary implications is the potential for CMS and other payers to reconsider the strictness of their early adherence requirements. The study provides robust real-world data indicating that patients can overcome initial adherence challenges and still derive significant benefits from CPAP therapy. This could lead to policy changes that allow for more flexibility, potentially preventing premature discontinuation of therapy for individuals who, with continued support or a slightly longer adjustment period, might become consistent users.
The study also underscores the importance of patient-centered outcomes. While device usage data is valuable, it does not tell the whole story. The researchers acknowledge that this conference abstract reports device-use data rather than symptom improvement or clinical outcomes. Future research could further strengthen these findings by correlating long-term CPAP usage, even in initially nonadherent patients, with improvements in sleep quality, reductions in daytime sleepiness, and positive impacts on cardiovascular health markers. This shift in focus from a purely quantitative measure of usage to a qualitative assessment of patient well-being could revolutionize how treatment success is defined and reimbursed.
Furthermore, the study’s setting within an integrated healthcare system that maintained coverage regardless of early adherence is a critical caveat. The findings may not directly generalize to healthcare settings where therapy is withdrawn after early nonadherence. In such scenarios, patients might be more likely to abandon therapy altogether due to financial concerns or the inability to access necessary equipment and supplies. This highlights the interconnectedness of adherence policies and patient access to care.
The identified demographic and socioeconomic factors associated with lower adherence also point to the need for targeted interventions. Younger patients, women, individuals from minority ethnic backgrounds, and those with lower socioeconomic status may face unique barriers to CPAP therapy. These could include a lack of understanding about OSA, challenges in navigating the healthcare system, financial constraints, or cultural factors. Healthcare providers and policymakers should consider developing tailored support programs, educational resources, and financial assistance initiatives to address these disparities and improve adherence across diverse patient populations.
The citation for this study, Billings M, et al. Reevaluating the Centers for Medicare and Medicaid Services 90-day CPAP adherence requirement: persistent use among early nonadherent patients, published in the Am J Respir Crit Care Med. 2026;212, with a DOI of https://doi.org/10.1093/ajrccm/aamag162.6465, points to its presentation at a significant medical conference, indicating its reception and discussion within the pulmonary and critical care medicine community. This abstract represents a crucial step in the ongoing dialogue surrounding the efficacy and accessibility of CPAP therapy for millions of individuals affected by obstructive sleep apnea.
In conclusion, this research provides compelling evidence that the rigid 90-day CPAP adherence requirement set by CMS may be overly simplistic and potentially detrimental to patient care. By demonstrating that a significant number of patients who initially fail to meet this benchmark continue to use CPAP therapy effectively, the study advocates for a more nuanced, patient-centered approach to assessing treatment success. This could involve extended observation periods, consideration of patient-reported outcomes, and a deeper understanding of the multifaceted barriers to adherence, ultimately aiming to improve long-term health outcomes for individuals with obstructive sleep apnea.
