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
Donna Appell RN
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 Public Comment on Proposed Changes to Lung Allocation Scoring
On behalf of the Hermansky-Pudlak Syndrome (HPS) Network, I respectfully submit the following comments regarding the proposed changes to the Lung Allocation Scoring system.
The HPS Network is the only international organization dedicated to supporting individuals and families affected by Hermansky-Pudlak Syndrome (HPS), a rare genetic disorder characterized by albinism, a severe bleeding disorder, immune dysfunction, inflammatory bowel disease, and, in several subtypes, progressive pulmonary fibrosis. For individuals with HPS pulmonary fibrosis, lung transplantation is currently the only life-extending treatment option.
We are deeply concerned that the proposed allocation changes may unintentionally disadvantage patients who are short in stature, very tall, have type O blood, or have increased HLA sensitization. While these factors individually present challenges for many transplant candidates, they create an even greater burden for people living with HPS.
Because HPS is associated with a significant platelet storage pool deficiency, patients frequently require platelet transfusions throughout their lives for surgeries, severe bleeding episodes, and other medical procedures. These medically necessary transfusions increase the likelihood of developing HLA antibodies, making it substantially more difficult to identify compatible donors. HPS patients do not become sensitized by choice; sensitization is often the unavoidable consequence of life-saving medical care required because of their underlying disease.
Reducing allocation priority for highly sensitized candidates would therefore have a disproportionate impact on individuals with HPS. These patients already face extraordinary barriers to transplantation due to the rarity of their disease, the complexity of their bleeding disorder, and the limited number of transplant centers experienced in their care. Adding another obstacle based on antibody levels would further reduce equitable access to the only therapy capable of extending their lives.
Any reduction in allocation priority related to body size could further decrease transplant opportunities for this rare patient population.
We strongly encourage the committee to carefully evaluate how these proposed scoring changes may disproportionately affect patients with rare diseases and medically necessary sensitization. Allocation systems should strive not only for efficiency but also for fairness by recognizing circumstances in which biologic characteristics and prior life-saving medical treatments create unavoidable disadvantages.
The HPS Network respectfully requests that the committee reconsider these proposed changes or incorporate appropriate adjustments so that highly sensitized patients, those with type O blood, and individuals requiring more difficult donor matching because of body size are not placed at an even greater disadvantage. Rare disease patients should not receive fewer opportunities for transplantation because of complications that are inherent to their disease or the medical treatments required to keep them alive while awaiting transplant.
Thank you for considering these comments and for your continued commitment to ensuring an equitable and evidence-based lung allocation system for all patients.
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,
Donna Appell RN
I am a histocompatibility lab director in Region 1, and I am particularly interested in the impact of the change in allocation weights on the population of highly sensitized lung transplant candidates. I am concerned that the decrease in the % of available points for the CPRA attribute, paired with the increase in the % of available points for placement efficiency, will reduce access to transplant for highly sensitized candidates by decreasing the number of opportunities to find those rare donors who are HLA-compatible. I do not see any modeling data that addresses this particular population. It will be important to see how transplant rates have changed since policy implementation, and to weigh any decrease in access for candidates with tougher-to-match biology against the possible benefits of decreasing out of sequence allocation. Careful analysis of the true cause and effect of any change in out of sequence allocation will also need to be performed, since it appears that out of sequence allocation had already significantly declined prior to policy approval.
Moeller Family
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 we have a lung transplant candidate family member. It's imperative recommendations by the National Lung Committee of Board be part of any policy changes to the existing Lung Transplant Continuous Allocation Scoring 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,
Moeller Family
Barbara A G Iams
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 lung transplant recipient - it saved my life which has made a significant impact in my life and family. I do not think that this change needed to be emergent without the proper modeling occurring on the impact to people located in lower populated/large spaces of geographical areas representing multiple states, medical conditions, and without input from the lung transplant professionals.
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,
Barbara A G Iams
RE: Update on Lung Continuous Distribution Policy
LifeLink® of Florida appreciates the opportunity to provide public comment on the Update on Lung Continuous Distribution Policy. As an organ procurement organization, LifeLink of Florida supports efforts to strengthen allocation integrity, reduce unnecessary barriers to organ placement, and mitigate avoidable organ non-use in a manner that honors donor families and best serves patients awaiting a life-saving transplant.
LifeLink of Florida recognizes that Allocation Out of Sequence (AOOS) is a concern that warrants thoughtful attention. The integrity of the allocation system depends on a shared commitment among OPOs, transplant programs, the OPTN, HRSA, and other stakeholders to support efficient, equitable, and policy-compliant organ allocation while preserving appropriate safeguards against organ non-use.
Our comment is focused on the policy development and governance process, particularly the apparent disconnect between the recommendation of the OPTN Lung Transplantation Committee and the final decision made by the OPTN Board of Directors. LifeLink of Florida acknowledges the concern reflected in many public comments that stakeholders do not fully understand why the Board proceeded with a policy change that did not align with the recommendation of the organ-specific committee charged with bringing clinical and technical expertise to lung allocation policy.
LifeLink of Florida respects the authority and responsibility of the OPTN Board to make final policy decisions, including decisions that require balancing clinical, operational, ethical, and system-level considerations. At the same time, when the Board reaches a decision that differs from the recommendation of an expert committee, it is important for the Board to clearly acknowledge that recommendation, explain the rationale for departing from it, and identify how the committee’s expertise will continue to inform implementation, monitoring, and future policy refinement.
The OPTN committee structure is a critical mechanism for incorporating specialized clinical knowledge, patient-centered considerations, operational experience, and real-world transplant system expertise into national policy. Organ-specific committees are uniquely positioned to evaluate how changes may affect medically complex candidates, biologically disadvantaged candidates, pediatric candidates, transplant program behavior, offer acceptance practices, and the broader balance of system equity and utility. Their recommendations should therefore be treated as a central part of the policy record and visibly accounted for in Board deliberations and decisions.
LifeLink of Florida encourages the OPTN Board to take seriously the concerns raised by the Lung Transplantation Committee and by members of the broader transplant community. In particular, LifeLink of Florida encourages greater transparency regarding the evidence considered, the rationale for the selected policy approach, the reasons for not adopting the Lung Committee’s recommendation, and the safeguards or monitoring that will be used to assess unintended consequences.
This is especially important when a policy change affects the relative weight of placement efficiency compared to other allocation factors. Efforts to improve efficiency and address AOOS should be carefully balanced against the need to preserve patient-centered allocation principles, including medical urgency, expected post-transplant benefit, pediatric priority, biological disadvantage, and equitable access to transplant.
LifeLink of Florida remains committed to supporting allocation integrity, improving organ placement, and engaging constructively with HRSA, the OPTN, OPOs, transplant programs, patients, donor families, and other stakeholders to ensure that allocation policy is evidence-based, transparent, equitable, and worthy of public trust.
Thank you again for considering these comments and for the continued work to advance a safe, ethical, and trusted donation and transplantation system. We remain appreciative of the volunteers and OPTN staff who steward policy development and implementation, often under complex clinical and operational realities. We would welcome the opportunity to support further discussion or provide additional operational perspective as the OPTN finalizes this proposal.
Darren Lahrman, MBA, BSRC, CPTC
Executive Director
LifeLink of Florida