Update on Lung Continuous Distribution Policy

Peter Schwob
State of Residence: South Carolina

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because medical conditions should come first. As a 20 year lung recipient I feel the 55 or so OPO are best qualified to make the guidelines.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Peter Schwob

Solana
State of Residence: California

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I would not be here without a lung transplant. At the time of my transplant, I was on the list for six weeks. Under the new guidelines, my wait time would have been extended and I would not have survived to have my transplant. My lung transplant has given me 13 extra years. Others deserve that same chance.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Solana

Toni Boyd
State of Residence: Washington

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I have a loved one who is awaiting a lung transplant and will be seriously impacted by this decision to change the CAS system while bypassing normal protocols. This decision has REAL life consequences and this could very well result in my loved one losing the opportunity to get her desperately needed lung transplant in time. This is just not acceptable to me and my family. This change was made without hearing the voices of those most knowledgeable and those most impacted by the decision. Additionally, the problem of allocation out of sequence had already resolved itself.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Toni Boyd

Daniel Ungier
State of Residence: Maine

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because of a close friend who has required more than one lung transplant in their lifetime. I know this is stating the obvious, but the allocation of points is literally a life or death issue.

My friend has taken the time to explain the issue at length to me, including the reduced mortality outcomes that the CAS system helped foster. What I find especially concerning as a citizen who cares both about my friend and overall health outcomes for Americans in need of organ transplants is that seventeen distinct lung disease patient advocacy organizations identified multiple concerns that led to opposing this change to the CAS. The proposed policy change not only seems likely to create worse outcomes for my friend and others, from the materials I have read, it is not supported by evidence-based science, not supported by experts, professionals, and patients who have devoted their time and expertise to the field, and is not supported by a rigorous and vetted review process that prioritizes careful decision making that leads to reduced mortality outcomes.

As other comments on this site have stated, I find it very concerning that the Lung Committee unanimously opposed this change to the CAS, and that no responses were given regarding initial modeling suggesting that these changes would increase the waitlist mortality for high-risk individuals. This is a committee of experts, and for there to be unanimous opposition to the change speaks volumes about whether the change was grounded in research or in the priorities of effectively creating best possible outcomes for those in need.

As others have said, but is so well worded, I too sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Daniel Ungier

Lori Kruse
State of Residence: Washington

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because Medical professionals are the only informed people who can safely make match determinations.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Lori Kruse

Aaron Trimble, MD
State of Residence: Oregon

Relationship to Lung Transplant: Transplant Professional

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because of the patients I care for and the concerns I have about their availability to receive organs.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Aaron Trimble, MD

Benji Kahn
State of Residence: Oregon

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I have dear friends for whom this is a life or death situation.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Benji Kahn

Andrea Pinuela
State of Residence: Indiana

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because Please don't let transplant patients die on the wait list. This change will cause harm. Stop it now.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Andrea Pinuela

Paul K. Sun Jr.
State of Residence: North Carolina

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because lung transplant recipients are in a desperate situation. The number of patients needing a transplant far exceeds the number of lungs available for transplant. Their lives depend on getting a transplant. This change will lead to more deaths of patients without improving the system.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Paul K. Sun Jr.

HRSA and OPTN needs to listen to the professionals

Diane K Garcia
State of Residence: New Mexico

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because My husband, Joe Garcia, has been on a lung transplant list for 3 years and 3 months. He is a hard to match recipient. During this time, I have watched his health decline. This change will bring him down on the list and make it harder to get a match for him, risking his life. We don't know how much time he has left.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Diane K Garcia

Joe F Garcia
State of Residence: New Mexico

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I have been on the lung transplant list for over 3 years. This change will directly affect me by moving me down on the list and making it harder for me to receive new lungs. Please return the CAS point allocation and ratios pre-November 20, 2025 votes.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Joe F Garcia

I write in strong support of the proposed update to the Lung Continuous Distribution policy increasing the weight on placement efficiency to 15% with a proportional reduction across the remaining Composite Allocation Score (CAS) attributes.

While allocation out of OPTN sequence (AOOS) remains lower in lung than in some other organs, its very existence is fundamentally inequitable to candidates on the waiting list. Two features of the recent AOOS pattern in lung allocation are particularly concerning. It has been occurring surprisingly early in the match at low allocation sequence numbers (15-20). While one understands AOOS can occur in situations like unstable donors etc. these should be fairly infrequent or rare events. Secondly, the rate fell sharply once HRSA and the OPTN focused attention on it. A behavior that dramatically recedes under scrutiny is consistent with patterns of allocation likely favoring some centers in coordination with OPOs. The OPTN Final Rule requires policies that promote and distribute organs equitably, and a structural policy change is the appropriate response.

The increase in median donor to recipient distance under continuous distribution is often dismissed as a minor concern. It is not minor for less resourced or smaller transplant programs. Greater distances impose logistical and financial burdens on smaller centers, and those burdens fall hardest precisely when such a center has a candidate ranked above the recipient who ultimately benefited from an out-of-sequence placement. Ischemic times have also lengthened as a result although there is little evidence that this has translated into worse outcomes. Addtionally, the centers best positioned to recover lungs over long distances are often those with the resources to contract for advanced preservation and transport technology. The availability of these systems may itself be an independent contributor to AOOS, allowing well-resourced programs to reach distant donors and encourage OPO’s to bypass local or regional candidates for whom such technology would not be necessary. This also materially increases the per-transplant cost of the system, a cost ultimately borne by payers and patients.

I want to directly address the concern that this change strips points from biologically disadvantaged or pediatric candidates. The reduction is applied proportionally and uniformly across every non-efficiency CAS attribute, so the relative weighting among waiting-list survival, post-transplant survival, candidate biology, and patient access remains unchanged. No clinical or equity attribute is singled out. It is also worth noting that these attributes do not share a common point distribution: waiting-list survival uses a convex transform that concentrates points among the sickest candidates and typically dominates the composite score, whereas post-transplant survival is essentially linear and contributes more uniformly. Because the rescaling is a single multiplicative factor, these distributions are preserved intact. The only change is the intended one, a modest increase in placement-efficiency weight that improves locoregional organ distribution and the projected reduction in the median travel distance for organ recovery teams.

Because these changes have been enacted by emergency action ahead of public comment, I strongly support the need for close monitoring of the post-implementation phase outlined in the proposal. Closely tracking waitlist mortality and post-transplant outcomes stratified by medical urgency, blood type, sensitization, and candidate stature will ensure that the increased weight on placement efficiency does not produce any meaningful rise in waitlist mortality or any deterioration in post-transplant survival. I urge that these metrics be reviewed against the pre-implementation baseline at clearly defined intervals (6 months at the very least), and that the results be made transparent to the community.
Respectfully,
Thomas Kaleekal, M.D.
University of Alabama at Birmingham

Sean Trew
State of Residence: Washington

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because as a bilateral lung recipient and having had a loved one become a heart donor that fairness and transparency in this process is paramount.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Sean Trew

Teresa Roberts
State of Residence: Indiana

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I am in the early stages of pulmonary fibrosis at the age of 39 due to a rare genetic mutation. I will need a lung transplant one day. I am married with 4 children, and I would hate to see a decision like this potentially negatively impact many people and families like mine.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Teresa Roberts

Thomas Lewis
State of Residence: Washington

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because Since diagnosis, my sister-in-law has gone from 50% in two lungs, to 30% in one. She has only a few months to live. She has passed all the tests on multiple occasions, her caregivers have been trained, and her go bag is packed. She is a prime transplant candidate.

You must overturn the November 20, 2025 decision, that favors prioritizing "Placement Efficiency" over medical necessity.

By prioritizing placement efficiency, you could well be contributing to her death, at the age of 61.

Do not choose placement efficiency.

Be forewarned: if you maintain your decision regarding placement efficiency, I guarantee you, you will see many caregivers in court.

Sincerely,

Thomas Lewis

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Thomas Lewis

Amy Buccola
State of Residence: Oregon

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I am an RN and care for many people who need organ transplants. Use of the current allocation score does not help those in greatest need, and makes the current process unwieldly. Please, PLEASE, reverse the decision. Many lives are depending on you.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Amy Buccola

[Your Name]
Oklahoma

Relationship to Lung Transplant: Community member and caregiver of a lung transplant candidate

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for the HRSA and OPTN Board of Directors to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocate them to the efficiency category, returning the CAS point allocation and ratios to the pre-November 20, 2025 vote levels.

This matters to me because my family is directly impacted by severe lung disease. My mother is living with pulmonary fibrosis, emphysema, and pulmonary hypertension and has undergone evaluation for lung transplantation. As a caregiver and family member, I understand how critical it is that the sickest patients have fair access to lifesaving donor lungs. Decisions that reduce the emphasis on medical urgency and increase the emphasis on efficiency raise serious concerns for families like mine who depend on a transplant system that prioritizes clinical need.

I am also concerned by the process used to implement these changes. Policies that can affect waitlist mortality and access to transplantation should be supported by robust clinical evidence, extensive modeling, meaningful public engagement, and the expertise of lung transplant professionals. Patients, caregivers, and clinicians deserve confidence that changes to the allocation system are thoroughly evaluated before implementation.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

• Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.

• No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested these changes would increase waitlist mortality for high-risk individuals.

• The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.

• Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates and recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,

Megan Butler

Wendy Aronson
State of Residence: Colorado

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because My sister is a double lung transplant survivor who currently is on the waitlist for a second transplant. She needs clarity on how the CAS works and confidence that the system in place has been backed by medical experts.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Wendy Aronson

Karli Sherwinter
State of Residence: Colorado

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because my dear friend's sister is a lung transplant recipient. Her transplant saved her life, but with the new OPTN board decision, she might not have been eligible to receive her transplant.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Karli Sherwinter

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because there are people I care deeply about whose lives are being jeopardized by this decision.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Benjamin Barnett

Shane Lymer
State of Residence: Kansas

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because My mother, Cynthia Lymer, has been on the lung transplant list for 3 years in July. She was initially given a year once the diagnosis was made but has managed and battled through to now. With every passing day, the disease has worsened. She is required to go to Integris monthly which seems to be the same song and dance for the last few years. Though I understand that offerings can be hard to come by with her size, these new restrictions will only make it more difficult.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Shane Lymer

Mackenzie Schweiger
State of Residence: Washington

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I am a recent lung transplant recipient. The policies that were previously in place saved my life. I was 38, on 100 liters of oxygen, and type O blood at the time I was placed on the wait-list. I have a wife and twin 9 year old boys. The previous policys helped ensure I was a priority and saved my life.

The new changes, against the advice of the Transplant community, and the committee of health official, are certain to cause unjust mortality. Do the right thing.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Mackenzie Schweiger

Decisions made regarding lung transplants should be reviewed by medically qualified personnel and/or team only.

Jeff Cederbaum
State of Residence: Maryland

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I am a double lung transplant recipient.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Jeff Cederbaum

We write as medical and surgical directors of lung transplant programs in California and Washington to oppose the emergency amendment to the lung Composite Allocation Score (CAS) implemented by the OPTN on May 7, 2026. This change raised the weight of geographic placement efficiency from 10 to 15 points and adopted a steeper distance-weighting function. We are concerned this change was made without sufficient deliberation and will harm lung transplant candidates throughout the country, including reducing access to lung transplantation for patients in our states. The amendment does not advance the goals it is meant to achieve in a manner sufficient to justify these harms. We urge the OPTN to suspend this amendment and to reconsider any change of this kind through its normal modeling and public-comment process.
Our first concern is the process by which this change was made. Continuous distribution and the CAS were adopted in 2023 in large part to reduce geographic disparities in donor lung allocation and to prioritize medical urgency, expected benefit and access for biologically disadvantaged candidates. The May 2026 emergency amendment moves in the opposite direction, increasing the prioritization of geography, in conflict with the Final Rule. Yet, the amendment was implemented without public comment, over the opposition of the OPTN Lung Transplantation Committee, and despite concerns expressed by the lung transplant community that this change would worsen geographic disparities in lung transplant waitlist outcomes. A change of this magnitude, which contradicts the established principles of donor organ allocation, should have been subject to the full scrutiny of the standard vetting process.
Second, the consequences of the amendment, which were not transparently reported prior to implementation, are likely to cause significant harm to lung transplant candidates across the country, and especially so in California and Washington. A recently published analysis by Valapour and colleagues (Chest 2026 May 22:S0012-3692(26)00652-5. doi: 10.1016/j.chest.2026.05.019) highlights and quantifies these consequences. They find that access to compatible donors was already strongly shaped by geography even before the emergency amendment was implemented, with West Coast centers having approximately 30% lower adjusted donor availability than those in the Midwest. Applying the emergency amendment’s parameters decreases donor availability in every region. Further, it more than doubles the already significant gap between the best- and worst-geographically positioned centers. This negative impact disproportionately affects lung transplant centers in California and Washington, leaving our patients with the worst adjusted donor supply in the nation and at a significant disadvantage for undergoing life-saving lung transplants. Patients in California and Washington are as deserving of access to lung transplantation as patients elsewhere in the country.
Our third concern is the lack of clarity on whether the amendment will even achieve its intended goals, and that any putative benefits with respect to these goals were not balanced against the foundational principles of donor organ allocation as stated in the Final Rule. We recognize the burden of long-distance procurement and understand that allocation out of OPTN sequence (AOOS) is a real and pressing problem. However, improvements in organ preservation technology and logistics are already diminishing the negative impacts of distance on efficiency, and the potential efficiency benefits of the amendment remain undefined and unproven. The emergency amendment is a blunt instrument that may or may not reduce AOOS or improve efficiency, while the potential harms to lung transplant candidates in California, Washington and across the country have now been clearly quantified. These conflicting priorities should have been defined, analyzed and debated prior to the implementation of any change.
Untested efforts to promote efficiency and reduce AOOS should not come at the cost of worsened waitlist outcomes for lung transplant candidates. This is especially true when there are disproportionate negative impacts on patients who happen to live further from the geographic center of the country. By prioritizing donor lung allocation based on geography rather than medical considerations, the emergency amendment operationalizes the happenstance of geography into reduced access, longer waiting times and more waitlist deaths. This is precisely the type of disparity that continuous distribution was created to remedy.
We therefore ask the OPTN to:
(1) revoke the May 7, 2026 amendment; and
(2) subject any future change in placement-efficiency weighting to full modeling and public comment, with transparent reporting of anticipated regional and center-level effects on waitlist outcomes before any changes are implemented.
We make these requests out of our sense of responsibility to the patients we serve and who will be harmed by this new policy, and we welcome the opportunity to work with the OPTN as this issue is reconsidered.
Respectfully,
Kamyar Afshar, DO
Medical Director, UC San Diego Lung Transplant Program

Abbas Ardehali, MD
Surgical Director, UC Los Angeles Lung Transplant Program

Gundeep Dhillon, MD, MPH
Medical Director, Stanford Lung Transplant Program

Sivagini Ganesh, MD
Medical Director, University of Southern California Lung Transplant Program

Eugene M. Golts, MD, MBA
Surgical Director, UC San Diego Lung Transplant Program

Steven Hays, MD
Medical Director, UC San Francisco Lung Transplant Program

Jasleen Kukreja, MD, MPH
Surgical Director, UC San Francisco Lung Transplant Program

Erika Lease, MD
Medical Director, University of Washington Lung Transplant Program

John W. MacArthur, MD
Surgical Director, Stanford Lung Transplant Program

Dominick Megna, MD
Surgical Director, Cedars-Sinai Lung Transplant Program

Michael S. Mulligan, MD
Surgical Director, University of Washington Lung Transplant Program

Reinaldo Rampolla, MD
Medical Director, Cedars-Sinai Lung Transplant Program

David M. Sayah, MD, PhD
Medical Director, UC Los Angeles Lung Transplant Program

Jonathan Singer, MD, MS
Associate Medical Director, UC San Francisco Lung Transplant Program

Maria Schweiger
State of Residence: Washington

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because with this new change lives are at risk. My husband who received his DLT over a year ago would not be with us today if he fell under the new policy. My young children would not have their father.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Maria Schweiger

Robert Lee Conley
State of Residence: New York

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because Why would you want to make it harder to obtain a transplant? My great nephew is alive only because he was able to receive a double lung transplant. Under the rules that you have now set he would probably no longer be with us.
Making it harder to qualify to my way of thinking means that more people will pass away as they sit on the waiting list that would have received a transplant under the old rules.
My great nephew would most likely be one who did not qualify under the new rules that you are imposing.
Think about what you are doing and go back to the old way. Don't change horses in mid stream.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Robert Lee Conley

This new procedure is patently unfair to lung trnafer recipients. Please change it back. It is a matter of life and death. Sincerely, Deborah Wolf

Pam Lackey
State of Residence: Oklahoma

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because It is affecting my ability to get lungs. My biological factors are O+ blood type, 5'0", and I'm listed at what's considered a "rural" lung transplant center. With the new allocation system, all these factors put me at a disadvantage. I am unfairly penalized and will have to wait longer for lungs. The current CAS need to be reversed.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Pam Lackey

Marshall Lymer
State of Residence Kansas

Relationship to Lung Transplant
Husband/Caregiver

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because My name is Marshall Lymer, I'm the husband/caregiver for Cynthia Lymer a lung transplant candidate. I don't completely understand all the changes that have been made to the transplant program so I'm just going to share our story.

July of 2021, I retired after a 48-year career as Auto mechanic. After retiring and being at home I found I could not get my wife to get out and go anywhere, she just would say she was too tired.
We'd went to the doctor several times and got a diagnosis of asthma or sinus infection or seasonal allergies. 

In August of 2022 we got a very light case Covid, kind of like a cold. Everything went downhill for her rapidly after that. I took her back to the doctor and told him he needed to do a chest x-ray because there's something wrong with this woman. He listened to her and said your right I need to do a chest x-ray. After the chest x-ray, he came in and said he didn't even know what he's looking at he's never seen anything like that. Off to cardiologist after that all checked out okay then to a pulmonologist. After a lung biopsy and the diagnosis of ILD off to Integris Hospital Transplant Center in OKC.
After their evaluation we were told she probably wouldn't live a year if she didn't get a transplant. After all their testing and 70 lb. weight loss we finally got her on the list July of 2024.

And here we are sitting, bags packed ready to go when they call! We go nowhere as she has no immune system and we've been told if she caught something it would kill her. I resigned my position as Elder in our church and we watch Church online, if I get sick, I'll just bring it home to her. We sold our camper our boat and my little 1975 Porsche 914 that's been in the family since new. Can't use them so may as well cut expenses.

And here we sit! She's getting weaker every day and unable to do anything. Going into this we thought we'd be on the other side of this thing by now, and here we sit! My wife is 4 ft11 so her size appears to be the big obstacle. Our Dr's are as frustrated as we are at the lack of offerings for lungs.
At this point this feels like the long goodbye, something needs to happen soon!

There's 3 parts to everything in life; there's our part, we have done that. There's God's part, he is doing that, we could not have made it this far without his mercy, strength, and provision. Then their other people's part. There-in seems to be the problem. These numbers you look at to make decisions on policy changes are people like us. Remember that as you contemplate how you choose which person gets lungs. Thanks for listening. 

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Marshall Lymer

Lisa Craig
State of Residence: Florida

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because Do not change the transplant priority rules. Type O blood is most common and eliminating priority will be detrimental to the most common in need and the most eligible recipients!

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Lisa Craig

Lisa Craig
State of Residence: Florida

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because Do not change the transplant priority rules. Type O blood is most common and eliminating priority will be detrimental to the most common in need and the most eligible recipients!

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Lisa Craig

We write as medical and surgical directors of lung transplant programs in California and Washington to oppose the emergency amendment to the lung Composite Allocation Score (CAS) implemented by the OPTN on May 7, 2026. This change raised the weight of geographic placement efficiency from 10 to 15 points and adopted a steeper distance-weighting function. We are concerned this change was made without sufficient deliberation and will harm lung transplant candidates throughout the country, including reducing access to lung transplantation for patients in our states. The amendment does not advance the goals it is meant to achieve in a manner sufficient to justify these harms. We urge the OPTN to suspend this amendment and to reconsider any change of this kind through its normal modeling and public-comment process.
Our first concern is the process by which this change was made. Continuous distribution and the CAS were adopted in 2023 in large part to reduce geographic disparities in donor lung allocation and to prioritize medical urgency, expected benefit and access for biologically disadvantaged candidates. The May 2026 emergency amendment moves in the opposite direction, increasing the prioritization of geography, in conflict with the Final Rule. Yet, the amendment was implemented without public comment, over the opposition of the OPTN Lung Transplantation Committee, and despite concerns expressed by the lung transplant community that this change would worsen geographic disparities in lung transplant waitlist outcomes. A change of this magnitude, which contradicts the established principles of donor organ allocation, should have been subject to the full scrutiny of the standard vetting process.
Second, the consequences of the amendment, which were not transparently reported prior to implementation, are likely to cause significant harm to lung transplant candidates across the country, and especially so in California and Washington. A recently published analysis by Valapour and colleagues (Chest 2026 May 22:S0012-3692(26)00652-5. doi: 10.1016/j.chest.2026.05.019) highlights and quantifies these consequences. They find that access to compatible donors was already strongly shaped by geography even before the emergency amendment was implemented, with West Coast centers having approximately 30% lower adjusted donor availability than those in the Midwest. Applying the emergency amendment’s parameters decreases donor availability in every region. Further, it more than doubles the already significant gap between the best- and worst-geographically positioned centers. This negative impact disproportionately affects lung transplant centers in California and Washington, leaving our patients with the worst adjusted donor supply in the nation and at a significant disadvantage for undergoing life-saving lung transplants. Patients in California and Washington are as deserving of access to lung transplantation as patients elsewhere in the country.
Our third concern is the lack of clarity on whether the amendment will even achieve its intended goals, and that any putative benefits with respect to these goals were not balanced against the foundational principles of donor organ allocation as stated in the Final Rule. We recognize the burden of long-distance procurement and understand that allocation out of OPTN sequence (AOOS) is a real and pressing problem. However, improvements in organ preservation technology and logistics are already diminishing the negative impacts of distance on efficiency, and the potential efficiency benefits of the amendment remain undefined and unproven. The emergency amendment is a blunt instrument that may or may not reduce AOOS or improve efficiency, while the potential harms to lung transplant candidates in California, Washington and across the country have now been clearly quantified. These conflicting priorities should have been defined, analyzed and debated prior to the implementation of any change.
Untested efforts to promote efficiency and reduce AOOS should not come at the cost of worsened waitlist outcomes for lung transplant candidates. This is especially true when there are disproportionate negative impacts on patients who happen to live further from the geographic center of the country. By prioritizing donor lung allocation based on geography rather than medical considerations, the emergency amendment operationalizes the happenstance of geography into reduced access, longer waiting times and more waitlist deaths. This is precisely the type of disparity that continuous distribution was created to remedy.
We therefore ask the OPTN to:
(1) revoke the May 7, 2026 amendment; and
(2) subject any future change in placement-efficiency weighting to full modeling and public comment, with transparent reporting of anticipated regional and center-level effects on waitlist outcomes before any changes are implemented.
We make these requests out of our sense of responsibility to the patients we serve and who will be harmed by this new policy, and we welcome the opportunity to work with the OPTN as this issue is reconsidered.
Respectfully,
Kamyar Afshar, DO
Medical Director, UC San Diego Lung Transplant Program

Abbas Ardehali, MD
Surgical Director, UC Los Angeles Lung Transplant Program

Gundeep Dhillon, MD, MPH
Medical Director, Stanford Lung Transplant Program

Sivagini Ganesh, MD
Medical Director, University of Southern California Lung Transplant Program

Eugene M. Golts, MD, MBA
Surgical Director, UC San Diego Lung Transplant Program

Steven Hays, MD
Medical Director, UC San Francisco Lung Transplant Program

Jasleen Kukreja, MD, MPH
Surgical Director, UC San Francisco Lung Transplant Program

Erika Lease, MD
Medical Director, University of Washington Lung Transplant Program

John W. MacArthur, MD
Surgical Director, Stanford Lung Transplant Program

Dominick Megna, MD
Surgical Director, Cedars-Sinai Lung Transplant Program

Michael S. Mulligan, MD
Surgical Director, University of Washington Lung Transplant Program

Reinaldo Rampolla, MD
Medical Director, Cedars-Sinai Lung Transplant Program

David M. Sayah, MD, PhD
Medical Director, UC Los Angeles Lung Transplant Program

Jonathan Singer, MD, MS
Associate Medical Director, UC San Francisco Lung Transplant Program

Patricia Wagner
State of Residence: Iowa

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I received a bilateral lung transplant in 1999. At that time, there was no scoring system, but there also was no medical center in my state that performed lung transplants. I was fortunate that I was able to have my transplant at the University of Minnesota, which is at least a 4-hour drive from my home. The recent changes to the CAS system make me fearful for people who do not live near a major medical facility and who may encounter longer, more harmful wait times.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Patricia Wagner

This follow-up comment reflects a partial revision of my prior submission dated May 24, 2026, based on further reflection and review of subsequent public comments.
I write to clarify and, in part, revise my prior position regarding the OPTN Board’s November 20, 2025 emergency action modifying the Lung Composite Allocation Score (CAS).
On further consideration, I believe HRSA may be moving in the correct strategic direction, particularly in increasing the weight of placement efficiency from 10% to 15%. My prior comment emphasized the equity costs of reweighting, but I now think that framing underappreciated the potential of placement efficiency as a structural lever to mitigate acuity escalation.
There is precedent in complex policy settings for expert committees to converge on suboptimal decisions through unintentional group reinforcement rather than deliberate error. It is therefore reasonable to allow for the possibility that HRSA’s intervention reflects a corrective response to such dynamics. In that context, transplant professionals and patients should extend a measured benefit of the doubt while continuing to evaluate outcomes rigorously.
I now view the increase in placement efficiency weight as a meaningful and potentially high-impact intervention. Its primary stated purpose is to reduce allocation out of sequence (AOOS) and improve policy compliance, but it may also help slow acuity runaway by reducing incentives to list and maintain candidates at extreme acuity. Over time, that could help avoid loss of cumulative survival from the onset of lung disease and reduce suffering among patients who present to transplant programs responsibly during a timely phase of illness.
This is especially relevant given the apparent increase in the proportion of candidates hospitalized at the time of transplant, which may serve as a surrogate marker of systemic drift toward higher acuity at allocation. There may be a short-term increase in waitlist mortality as the system re-equilibrates, and that should be monitored closely in forthcoming HRSA data releases. The longer-term effect, however, may be a net gain in cumulative survival from time of disease onset, a clinically meaningful outcome not captured in standard allocation metrics, along with a reduction in the duration of suffering among patients who present responsibly during a timely phase of illness.
I would also correct my earlier position regarding the proportional reduction in biological disadvantage, urgency, and post-transplant outcome weights. On reflection, the shift from 45% to 50% total allocation weight redistributed across attributes is unlikely to be materially important in isolation because the relative relationships among attributes are preserved. I therefore no longer view that proportional reweighting as a central concern, provided key structural protections, including CPRA, height, and blood type considerations, remain in place and are monitored for unintended effects.
I remain concerned, however, that blood type O candidates continue to languish longer than other blood groups on the waitlist despite prior corrective action. This suggests that the September 2023 adjustment may have been incomplete, and cumulative modeling of all ABO-related policy changes remains essential before further modification.
As noted in my prior comment, if further increases in placement efficiency weighting are considered, pediatric priority remains a logical source of marginal reallocation. Even at reduced levels, pediatric priority still confers a decisive and clinically appropriate advantage. This adjustment could enable additional efficiency gains and, if desired, further reduction in acuity escalation.
I also want to re-emphasize that allocation policy changes alone may not be sufficient to produce the intended reduction in acuity if the broader ecology has shifted since the 2017 continuous distribution era. The threshold for aggressive bridging interventions appears to have drifted in a system where interventions during the pre-transplant phase of care may be undertaken before waitlisting is secure in an already marginal candidate. For that reason, HRSA should advocate to CMS for reimbursement structures linked to meaningful long-term outcomes rather than procedural volume alone, encourage publication of center-level or program-level bridging metrics in relation to listing, transplant, and post-transplant outcomes, and strengthen informed-consent expectations so that patients and families understand the full pathway from bridging procedure to recovery, listing, transplantation, and meaningful survival. Without attention to that upstream ecology, allocation reform alone may not generate the degree of acuity moderation policymakers intend.
After reviewing additional perspectives, I also suggest considering reduction of the post-transplant survival horizon in CAS from 5 years to 4 or potentially 3 years. A shorter horizon may improve access for older candidates whose expected benefit is not fully captured under a 5-year model. This change would require careful modeling but may represent a pragmatic refinement of the current framework.
My revised view is that the November 2025 changes, particularly the increase in placement efficiency, should not be dismissed as a misstep, but instead evaluated as a potentially constructive intervention in a system struggling with persistent acuity escalation.
I appreciate the opportunity to revise my perspective and contribute to this ongoing policy discussion.
I am an employee of an OPTN member institution, but this comment is submitted in my personal capacity.

This follow-up comment reflects a partial revision of my prior submission dated May 24, 2026, based on further reflection and review of subsequent public comments.
I write to clarify and, in part, revise my prior position regarding the OPTN Board’s November 20, 2025 emergency action modifying the Lung Composite Allocation Score (CAS).
On further consideration, I believe HRSA may be moving in the correct strategic direction, particularly in increasing the weight of placement efficiency from 10% to 15%. My prior comment emphasized the equity costs of reweighting, but I now think that framing underappreciated the potential of placement efficiency as a structural lever to mitigate acuity escalation.
There is precedent in complex policy settings for expert committees to converge on suboptimal decisions through unintentional group reinforcement rather than deliberate error. It is therefore reasonable to allow for the possibility that HRSA’s intervention reflects a corrective response to such dynamics. In that context, transplant professionals and patients should extend a measured benefit of the doubt while continuing to evaluate outcomes rigorously.
I now view the increase in placement efficiency weight as a meaningful and potentially high-impact intervention. Its primary stated purpose is to reduce allocation out of sequence (AOOS) and improve policy compliance, but it may also help slow acuity runaway by reducing incentives to list and maintain candidates at extreme acuity. Over time, that could help avoid loss of cumulative survival from the onset of lung disease and reduce suffering among patients who present to transplant programs responsibly during a timely phase of illness.
This is especially relevant given the apparent increase in the proportion of candidates hospitalized at the time of transplant, which may serve as a surrogate marker of systemic drift toward higher acuity at allocation. There may be a short-term increase in waitlist mortality as the system re-equilibrates, and that should be monitored closely in forthcoming HRSA data releases. The longer-term effect, however, may be a net gain in cumulative survival from time of disease onset, a clinically meaningful outcome not captured in standard allocation metrics, along with a reduction in the duration of suffering among patients who present responsibly during a timely phase of illness.
I would also correct my earlier position regarding the proportional reduction in biological disadvantage, urgency, and post-transplant outcome weights. On reflection, the shift from 45% to 50% total allocation weight redistributed across attributes is unlikely to be materially important in isolation because the relative relationships among attributes are preserved. I therefore no longer view that proportional reweighting as a central concern, provided key structural protections, including CPRA, height, and blood type considerations, remain in place and are monitored for unintended effects.
I remain concerned, however, that blood type O candidates continue to languish longer than other blood groups on the waitlist despite prior corrective action. This suggests that the September 2023 adjustment may have been incomplete, and cumulative modeling of all ABO-related policy changes remains essential before further modification.
As noted in my prior comment, if further increases in placement efficiency weighting are considered, pediatric priority remains a logical source of marginal reallocation. Even at reduced levels, pediatric priority still confers a decisive and clinically appropriate advantage. This adjustment could enable additional efficiency gains and, if desired, further reduction in acuity escalation.
I also want to re-emphasize that allocation policy changes alone may not be sufficient to produce the intended reduction in acuity if the broader ecology has shifted since the 2017 continuous distribution era. The threshold for aggressive bridging interventions appears to have drifted in a system where interventions during the pre-transplant phase of care may be undertaken before waitlisting is secure in an already marginal candidate. For that reason, HRSA should advocate to CMS for reimbursement structures linked to meaningful long-term outcomes rather than procedural volume alone, encourage publication of center-level or program-level bridging metrics in relation to listing, transplant, and post-transplant outcomes, and strengthen informed-consent expectations so that patients and families understand the full pathway from bridging procedure to recovery, listing, transplantation, and meaningful survival. Without attention to that upstream ecology, allocation reform alone may not generate the degree of acuity moderation policymakers intend.
After reviewing additional perspectives, I also suggest considering reduction of the post-transplant survival horizon in CAS from 5 years to 4 or potentially 3 years. A shorter horizon may improve access for older candidates whose expected benefit is not fully captured under a 5-year model. This change would require careful modeling but may represent a pragmatic refinement of the current framework.
My revised view is that the November 2025 changes, particularly the increase in placement efficiency, should not be dismissed as a misstep, but instead evaluated as a potentially constructive intervention in a system struggling with persistent acuity escalation.
I appreciate the opportunity to revise my perspective and contribute to this ongoing policy discussion.
I am an employee of an OPTN member institution, but this comment is submitted in my personal capacity.

Teresa Randall
State of Residence: Washington

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I am a relative of a high risk double lung recipient in 12.2024. He would not be alive today with the new allocations in place. It is sad to see the transplant process go backwards and worry more about the bottom line than the transplant success rate of the actual recipient. Health scores are much more important than location and they provide a much higher chance of a successful transplant to those whose needs are critical.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Teresa Randall

Heather R Rekeweg
State of Residence: Virginia

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because These changes would likely have had dire consequences for me.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Heather R Rekeweg

Cynthia Lymer
State of Residence: Kansas

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because This matters to me because I am awaiting a lung transplant.
My story is like many others, my husband and I raised our children, we have been caregivers to our parents, I took care of grandkids while my kids worked.
My husband and I had plans for retirement, he retired and shortly after I started having lung issues.
They have no explanation for my ILD, most people that get what I have have worked around chemicals etc.
I have done none of that.
I am 4ft 11 so I feel this vote affects me.
I want to do the things my husband and I planned but at this point it is hard to just go anywhere, I am on 6 to 10 liters of oxygen, so it is hard to even go anywhere and have enough tanks. Some days just the effort to walk through the house and breathe feels like to much to withstand! I can’t really say when the last time I really felt good was!
My children have put their lives on hold helping take care of me.
I want to play with my small grandkids again. I have a 7 month old grandson and also a 8 month old great grandson that I can’t even carry around.
This breaks my heart.
My 7 year old granddaughter gathers her teachers and friends at school and asks them to pray that her grandma get lungs. She has her friends get in a circle at home and prays for me to get lungs.
These little ones have asked for this from Santa!
My young grandsons come in day after day asking “ grandma do you feel better today”. They ask me when I am going to get the call.
My 21 year old grandson moved here from Texas to help take care of me.
None of these things were prompted by their parents, they just did it.
These are such precious things and my heart bursts with love.
I am telling you this because these little ones should not be worrying about these things.
I have been on the list for 2 years now. We really thought we would be on the other side of this by now.
Please consider me in your decision making.
I want to get back to living again and Playing with my kids!
Thank you for allowing me to share!
Sincerely
Cynthia Lymer

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Cynthia Lymer

Tiffany Young
State of Residence: Kansas

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because My mother has been on the transplant list for 3 years now and was actually #3 on the list until this ridiculous policy change. We are only 2hours from a transplant hospital and now we are “too far.” How can that be?! How can you deny someone who is of the greatest need and give that to someone else simply because they aren’t in a huge city?! We have watched her health only continue to get worse. I am begging you to reconsider this policy change! My mom's children and grandchildren would love to get to spend many more years with her.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Tiffany Young

Jonathan Reynolds
State of Residence: Washington

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I have a loved one who is awaiting a lung transplant and is negatively impacted by these changes to the CAS.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Jonathan Reynolds

Coreen Mayerhofer
State of Residence: New York

Relationship to Lung Transplant: Living Organ Donor, Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I have a cousin currently on the list waiting for a lung transplant and she will be unfairly evaluated if these stipulations are not changed.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Coreen Mayerhofer

Linda Krueger
State of Residence: Minnesota

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I am a lung transplant patient of 2 years. I was very sick and only a year to live because of ILD,turning into hypersensitive. I moved up on the list because I was getting sicker and going down fast. The system worked for me and I have no idea why the policy has to change!? When things are working smoothly for patients and families why do you have to change them! I see absolutely no reason to change the way lung and other transplants are received. Apparently no one in your family has gone through a transplant to know how serious this change is! Please leave the transplant criterias without change! Peoples lives are at stake and you are messing with them! The HRSA/OPTN board needs to reverse the decision!

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Linda Krueger

Linda Graham
State of Residence: Kansas

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I have a friend who is waiting on a double lung transplant. She has done everything right, from her weight loss to making it to all her Dr's appointments. Now she is being told that her numbers will be down because she doesn't live close to a transplant center or hospital. If she were to get the call that there were lungs for her she will make it to the hospital in time. This is totally unfair, please reconsider this.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Linda Graham

Ranga Ramanujam

State of Residence: Tennessee

Relationship to Lung Transplant: Community member

I am writing as a concerned community member regarding the November 2025 changes to the Lung Transplant Continuous Allocation Score (CAS) that increased the weight assigned to placement efficiency.

While I am not a transplant professional, this issue is deeply personal to me. One of my closest friends is a multiple lung transplant recipient, and I am the godfather to her child. Over many years, I have witnessed the uncertainty, anxiety, and hope that accompany life on a transplant waiting list. Although I cannot speak as a patient, I have seen how allocation decisions can profoundly affect patients and their families.

I understand that one objective of the recent change was to address concerns about allocation out of sequence (AOOS) and improve adherence to the official allocation process. I support efforts to increase transparency, fairness, and public trust in the transplant system. Patients and families deserve confidence that organs are allocated according to clear and consistently applied rules.

My concern is not with that goal, but with the means chosen to achieve it. Increasing the weight assigned to placement efficiency appears to address a compliance and logistics problem by changing the factors that determine patient priority. While efficiency and successful organ placement are important considerations, medical urgency, expected benefit, and equitable access should remain the primary drivers of allocation decisions.

I am particularly concerned by reports that this change was implemented despite significant reservations expressed by lung transplant professionals, patient advocates, and the OPTN Lung Committee. I also note the concerns raised in the April 2026 letter submitted through the Critical Comments and Directives Pathway and supported by seventeen lung disease patient advocacy organizations. Among the issues identified were the absence of a prospective public comment period, questions about the justification for using an emergency pathway, concerns that initial modeling suggested increased waitlist mortality for some high-risk patients, and the apparent shift from extensive pre-implementation modeling toward identifying and addressing problems after implementation.

As someone whose professional life has been devoted to understanding organizations and decision-making, I recognize that reasonable people can disagree about the best allocation system. My concern is less about any particular technical formula than about process and evidence. When policy changes have the potential to affect life-and-death allocation decisions, especially for vulnerable patients, they should be supported by compelling evidence, broad professional engagement, and meaningful participation by patients and their advocates.

I therefore respectfully request that HRSA and OPTN reconsider the November 2025 CAS modification and carefully evaluate whether restoring the prior weighting of CAS components would better align the allocation system with the principles of medical need, equity, and patient-centered care. At a minimum, I urge transparent reporting of the policy's effects on waitlist mortality, access to transplantation, and equity across patient groups, together with continued engagement of transplant professionals, patients, families, and advocacy organizations.

For individuals waiting for a transplant, these are not abstract policy questions. They are questions of survival, time, and opportunity.

Thank you for your consideration.

Sincerely,
Ranga Ramanujam

Christie Lowe
State of Residence: Missouri

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because a family friend is awaiting a lung transplant and has been on the list for the past 3 years. It would be a shame that her medical necessity has less value to what is efficient or distance related. Evidence based clinical decisions should continue to take priority over what is considered convenient. Everyone deserves a fair chance the list placement.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Christie Lowe

My friend needs a double lung transplant. She has done everything the Dr's have asked of her. She should not be denied higher numbers because of her location

This decision should be reversed. I watched the presentation of the workgroup to the Board, and I was impressed by the Lung Committee's concern that implementing any change to allocation with the available data would be irresponsible, and their assessment that they could not predict the effects on patient transplant rate and survival. They (rightly) noted that the growing awareness of AOOS had made a significant dent in the problem without any formal change in the algorithm, and they were concerned that any change would materially disadvantage those of smaller stature, including pediatric patients.
The OPTN Board of Directors chose to overrule the unanimous opinion of the Lung Committee, and forge ahead with this change, and called it an emergency so grave that it could not wait for public comment. The reasoning given by the Board leadership was particularly odd - they claimed that they were being pressured by HRSA to make some change, no matter the justification. It then sat on the decision for 6 months before implementing it and then almost immediately putting it up for public comment. An incoherent approach, to say the least.
For anyone interested in the opinions of patients about this question, I recommend the following video: https://vimeo.com/1194217693.
This appears to be purely a political decision, rather than one based on strong data and statistical analysis. I should also note that the Patient Affairs Committee was not consulted on this topic, despite the overwhelming interest of patients on this subject.

Patrice Morris Ball
State of Residence: Oregon

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because our family has been impacted by several instances of organ donation and transplant, and one family member is now waiting for a future transplant.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Patrice Morris Ball