Current policy
Every lung transplant candidate receives an individualized lung Composite Allocation Score (CAS). This score determines priority for receiving a lung transplant when donor lung(s) become available. The lung CAS is individual for each candidate and each organ offer. The lung CAS point values represent each of the factors used to match organ offers with transplant candidates (Exhibit 1). The people who have the highest number of points for that organ offer will have the highest priority.
In October 2025, the Health Resources and Services Administration’s (HRSA) preliminary analyses documented a rise in allocation out of OPTN sequence (AOOS) that correlates with the implementation of the lung continuous distribution policy in 2023. In response, the OPTN Board of Directors considered potential changes to lung allocation to promote policy compliance and reduce AOOS.
Note: Certain changes described in this proposal were previously implemented following emergency action by the OPTN Board of Directors and are currently in effect while the proposal proceeds through the formal policy process.
Supporting media
Exhibit 1. Current Lung Composite Allocation Score
| Attribute | Definition | % of Available Points |
|---|---|---|
| Waiting List Survival | Expected 1-year waiting list survival | 25 |
| Post-Transplant Outcomes | Expected 5-year post-transplant survival | 25 |
| Candidate Biology | Total of ABO, CPRA, and height points | 15 |
| ABO | Based on percentage of compatible donors by blood type | 5 |
| CPRA | Based on percentage of compatible donors by CPRA | 5 |
| Height | Based on percentage of compatible donors by height | 5 |
| Patient Access | Total of pediatric and prior living donor points | 25 |
| Pediatric | For candidates under 18 years old | 20 |
| Prior Living Donor | For candidates who donated any organ | 5 |
| Placement Efficiency | Total of travel and proximity efficiency points | 10 |
| Travel Efficiency | Based on impact of distance on costs of travel | 5 |
| Proximity Efficiency | Based on impact of distance on other efficiency (time, availability, etc.) | 5 |
Note. Total Score = Waiting List Survival + Post-Transplant Outcomes + Candidate Biology + Patient Access + Placement Efficiency
Acronyms. ABO=ABO blood group system, CPRA=Calculated Panel Reactive Antibody
Proposed changes
- Increasing the weight on placement efficiency from 10% to 15% of the overall score.
- Reducing the weight on all other parts of the score proportionally, including points assigned to pediatric candidates less than 12 years old for waitlist survival and post-transplant outcomes.
- Replacing the existing travel efficiency and proximity efficiency rating scales with a single placement efficiency rating scale to assign points to potential transplant recipients based on the nautical mile distance between the donor hospital and the transplant hospital.
- Lung CAS scores for all lung and heart-lung candidates on the waiting list will be updated to reflect the changes to the lung CAS (Exhibit 2).
- Approved exceptions will remain in effect based on the percentage of available points approved by the Lung Review Board, and the points assigned for each exception will be reduced proportionately to the adjusted goal weights.
Exhibit 2. Revised Lung Composite Allocation Score
| Attribute | Definition | % of Available Points |
|---|---|---|
| Waiting List Survival | Expected 1-year waiting list survival | 23.6111 |
| Post-Transplant Outcomes | Expected 5-year post-transplant survival | 23.6111 |
| Candidate Biology | Total of ABO, CPRA, and height points | 14.1666 |
| ABO | Based on percentage of compatible donors by blood type | 4.7222 |
| CPRA | Based on percentage of compatible donors by CPRA | 4.7222 |
| Height | Based on percentage of compatible donors by height | 4.7222 |
| Patient Access | Total of pediatric and prior living donor points | 23.6111 |
| Pediatric | For candidates under 18 years old | 18.8889 |
| Prior Living Donor | For candidates who donated any organ | 4.7222 |
| Placement Efficiency | Total of travel and proximity efficiency points | 15 |
Note. Total Score = Waiting List Survival + Post-Transplant Outcomes + Candidate Biology + Patient Access + Placement Efficiency
Acronyms. ABO=ABO blood group system, CPRA=Calculated Panel Reactive Antibody
Anticipated impact
- What it's expected to do
- Reduce median travel distance for lungs
- Reduce logistical complexity in lung allocation
- Improve policy compliance
- What it won’t do
- It will not completely alleviate AOOS.
Terms to know
- Allocation out of OPTN sequence (AOOS): An organ allocation event in which an organ is offered, accepted, and/or transplanted outside the established match sequence.
- Composite Allocation Score (CAS): This score determines priority for receiving a lung transplant when donor lung(s) become available.
- Calculated Panel Reactive Antibody (CPRA): A score (0–100%) indicating the percentage of potential donors a patient is immunologically incompatible with due to antibodies.
Read the full proposal (PDF - 354 KB)
Submit a Comment
Kristin Hammes
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 medical need should ALWAYS be prioritized over efficiency. Additionally, the opinions of experts in the field and of those who have direct experience with how allocation impacts real lives should be heavily weighted in the decision making process.
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,
Kristin Hammes
Jodie Rodne
State of Residence: Minnesota
Relationship to Lung Transplant: Lung 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 recipient of a double lung transplant. Altering the CAS scoring will cause mortality rates to increase.
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,
Jodie Rodne
Diane Ramirez
State of Residence: North 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 I had a heart and lung transplant in 2023. I was on the list for 4 1/2 months and it felt like a lifetime. I couldn't breathe,even on high dose oxygen. I cannot imagine how horrible it would be to wait longer. Please reconsider this change.
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 Ramirez
The New York Cardiothoracic Transplant Consortium (NYCTC) submits these comments in response to the OPTN’s 2026 Update on the Lung Continuous Distribution Policy. NYCTC represents patients and transplant professionals across New York State who are committed to ensuring that lung allocation policy advances equity, medical urgency, and meaningful patient benefit. We appreciate the opportunity to participate in this public comment process.
We write with serious concerns on two fronts: the governance process by which this change was enacted, and its substantive impact on patient access to transplantation and waitlist outcomes. We urge the OPTN Board of Directors and HRSA to reconsider both before these changes are allowed to stand.
A Policy Change of This Magnitude Warranted Lung Committee Recommendation — and Did Not Have It
The original lung CAS was developed over two years through a deliberate, multi-stakeholder process that included nearly 200 clinicians, patients, and administrators; and conducted prioritization exercises and rigorous data modeling in partnership with researchers at MIT. The 2026 weight adjustments — increasing placement efficiency from 10% to 15% of the total score and reducing all other attributes, including points assigned to pediatric candidates for waitlist survival and post-transplant outcomes, proportionally — were not developed through any comparable process. They were advanced by the OPTN Board of Directors without a formal recommendation from the OPTN Lung Transplantation Committee, the body expressly charged with this work.
This is not a procedural technicality. The OPTN’s governance structure exists because lung allocation decisions carry life-and-death consequences that demand expert review before they bind the transplant community. A newly constituted Board acting on weight changes of this consequence — without Committee recommendation, without public modeling data, and outside the normal comment cycle — sets a troubling precedent that we ask the OPTN and HRSA to correct. We call on the Board to suspend these changes pending formal Lung Committee deliberation and recommendation, and to make the degree of Committee support for each element of the 2026 adjustment publicly available.
The New Placement Efficiency Weight Prioritizes Distance Over Dying Patients — Without Justification
The prior CAS assigned 10% of the total score to placement efficiency — a figure the Lung Transplantation Committee adopted after extensive modeling and deliberation specifically because simulation data showed that minimizing the placement efficiency weight reduced waitlist deaths for the highest-acuity candidates. The 2026 change raises that weight to 15% and correspondingly reduces the share of the score devoted to medical urgency, post-transplant outcomes, and pediatric priority. No comparable modeling has been shared with the transplant community to justify this rebalancing, and no public data has been released demonstrating that the prior weights were causing increases in lungs allocated out of sequence; that this change was supposed to address.
The practical effect is to advance candidates closer to a donor hospital over candidates who are sicker but farther away. Without outcome data showing that the original 10% weight was producing unacceptable inefficiencies, there is no evidentiary basis for accepting that tradeoff. Absent a clear and publicly verifiable justification, NYCTC supports reverting to the prior CAS calculations.
Patients Will Once Again be Subject to Geographic Bias in Access to Transplantation
The continuous distribution framework was designed, in part, to reduce the role of geography in determining who receives a transplant. By increasing the weight assigned to the distance between donor and transplant hospital, the 2026 change moves in the opposite direction. This effect will fall unevenly on patients who are already medically complex, who have waited longer, and who have fewer transplant options. We ask the OPTN and HRSA to require a regional impact analysis before these weight changes take permanent effect.
NYCTC supports the continuous distribution framework and recognizes that policy refinement is both appropriate and necessary. What we cannot support is a consequential change to allocation weights — one that touches every candidate on the waitlist, reduces pediatric priority, and shifts the balance away from medical urgency — implemented without Lung Committee recommendation, without public modeling, and without clear evidence. We urge the OPTN Board of Directors and HRSA to suspend the 2026 weight changes; to direct the Lung Transplantation Committee to review, model, and formally recommend any revisions through the standard policy development process; and to publish post-implementation outcome data before any further adjustments are adopted.
NYCTC is prepared to engage constructively in that process. Every patient on the lung transplant waitlist deserves an allocation system whose rules were made openly, with their interests at the forefront.
The HRSA/OPTN Board needs to reverse the decision voted on during the November 20, 2025, which got rid of the CAS score input.
I received a double Lung Transplant in 2020. I would've barely survived another couple of weeks, had I not received a new pair of lungs time.
Everyone who is down on the ground level of transplants does not agree with this incorrect "emergency" decision.
If everyone in-the-know wants this decision reversed, it make one wonder the REAL reason behind the choice to delete a functional system which embraced patients real-world timing needs.
The real reason is likely that someone makes more money off this.
Follow the money!
. . . and return the CAS.
Thank you,
Todd Ware - Bigfork, MT