Early CPAP nonadherence does not predict long-term treatment failure

Many insurers stop covering continuous positive airway pressure or CPAP devices if patients don't use them regularly in the first 90 days. But new research presented at the ATS 2026 International Conference shows that many patients who initially struggle to meet these early-use thresholds do go on to use and benefit from CPAP therapy.

The findings challenge long-held assumptions that poor early use predicts long-term CPAP use, said first author Dennis Hwang, MD, a sleep and pulmonary physician at Kaiser Permanente Southern California. These assumptions serve as the basis for a Medicare policy that requires patients with obstructive sleep apnea (OSA) to use their CPAP for at least four hours each night on 70 percent of nights during a 30-day window within the first 90 days to maintain coverage. That means patients who would ultimately benefit from CPAP may lose access to effective treatment, Dr. Hwang said.

Our findings suggest clinicians and policymakers should not rely solely on Medicare-defined adherence, given its reliance on early CPAP use and an arbitrary four-hour threshold, when making long-term treatment decisions. Extending support and coverage beyond the first 90 days could help more patients achieve meaningful benefit."

Dennis Hwang, MD, first author, sleep and pulmonary physician at Kaiser Permanente Southern California

For the study, researchers analyzed data on more than 132,000 patients treated for OSA within Kaiser Permanente Southern California, a system that offers CPAPs to patients regardless of whether they meet the early-use threshold.

Researchers found that 51 percent of patients didn't meet the 90-day Medicare criteria for continued use. However, more than one-third of patients who didn't meet the early Medicare use criteria were still using CPAP one year later. Importantly, even those who weren't meeting the four-hour threshold were still using the devices for at least two hours a night, an amount known to improve symptoms of sleep apnea, Dr. Hwang noted. The results suggest that early nonadherence doesn't equate to treatment failure, he said.

"These findings challenge a long-standing assumption in clinical practice and policy," he said. "While clinicians know some patients take time to adapt, the scale of continued use we observed in those that did not initially meet Medicare adherence was striking."

Next, researchers are planning additional studies to better understand which patients are most likely to become long-term CPAP users and evaluate evidence-based coverage policies that focus on patient outcomes rather than arbitrary usage thresholds, he said.