Reevaluating the CMS 90-Day CPAP Adherence Requirement: Persistent Use Among Early Nonadherent Patients

CLINICAL QUESTION

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?

BOTTOM LINE

More than one-third of patients who failed to meet the CMS 90-day adherence threshold were still using continuous positive airway pressure (CPAP) at one year, with average use sufficient to provide symptomatic benefit. These findings question the assumption that poor early adherence predicts treatment abandonment and support evaluating CPAP success using patient-centered outcomes rather than rigid usage criteria.

BACKGROUND: CMS requires early CPAP adherence to maintain coverage despite limited supporting evidence. This study evaluated long-term CPAP use and treatment abandonment in a healthcare system that continued coverage regardless of early adherence.

STUDY DESIGN: Retrospective observational cohort study of adults with obstructive sleep apnea who received CPAP between 2020 and 2023. Patients were stratified according to whether they met the CMS 90-day adherence threshold, and device use was evaluated during month 12, defined as days 330 through 360 after treatment initiation.

SETTING: Kaiser Permanente Southern California, an integrated healthcare system that continued CPAP coverage regardless of early adherence

SYNOPSIS: The analysis included 132,492 adults with at least one recorded CPAP-use episode during the first year after device dispensation. Mean age was 55.0 years, 65.5% were men, and mean apnea–hypopnea index using a 4% desaturation criterion was 32.5 events per hour.

Overall, 49.0% of patients met the CMS adherence requirement within 90 days. The proportion was higher among patients aged 65 years or older, at 53.5%. Failure to meet the requirement was associated with younger age, female sex, non-white race or ethnicity, lower socioeconomic status, and less severe obstructive sleep apnea. Among the 67,906 patients who did not meet the initial CMS threshold, 36.0% demonstrated some CPAP use during month 12. Among these continued users, mean use was 197 minutes per night, and CPAP was used for at least four hours on an average of 42.9% of nights.

Considering all patients who were initially CMS-nonadherent, 20.9% averaged at least two hours of CPAP use per night during month 12, and 13.6% averaged at least four hours. Corresponding rates among patients aged 65 years or older were 23.3% and 16.5%, respectively. The findings challenge the use of a fixed early-adherence threshold as a proxy for long-term treatment failure. However, this conference abstract reports device-use data rather than symptom improvement or clinical outcomes, and results from an integrated system that maintained coverage may not generalize to settings where therapy is withdrawn after early nonadherence.

CITATION: Billings M, et al. Reevaluating the Centers for Medicare and Medicaid Services 90-day CPAP adherence requirement: persistent use among early nonadherent patients. Am J Respir Crit Care Med. 2026;212. https://doi.org/10.1093/ajrccm/aamag162.6465.