Update on Lung Continuous Distribution Policy

Eric Burdick
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 My wife got her transplant after 21 days on the list the need was urgent and we got the call for new lungs quickly, the timing was everything for us. Please, don’t change this process. It helps so many live longer fuller lives.

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,
Eric Burdick

Edie Sperling
State of Residence: Oregon

Relationship to Lung Transplant: Living Organ Donor

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 on the transplant list. She, like everyone else who finds their name on this list, will die without a lung transplant. Doctors are willing to do the transplant, people are signed up as organ donors, and people are waiting on organs so they can live. The process for getting your name listed is intense. Only people who really need lungs are on the list, which means there's no time to waste.

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,
Edie Sperling, PhD

Laura Reynolds
State of Residence: Pennsylvania

Relationship to Lung Transplant: Family 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 familial pulmonary fibrosis affects my family directly. I strongly believe in evidence-based decision making in clinical settings, and this emergency change appears to prioritize logistical convenience over patient outcomes. There is no evidence that deprioritizing patient criteria in favor of administrative ease will save more lives and it will likely cost them.

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,
Laura Reynolds

Alvaro Lucci
State of Residence: Pennsylvania

Relationship to Lung Transplant: Living Organ Donor

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 living organ donor and believe transplant allocation should prioritize medical urgency and fairness for patients in greatest need.

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,
Alvaro Lucci

George B. Hall
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 personal family friend with a lung transplant patient, who has experienced 10 additional years of life due the the gift of a lung transplant. That person is now been approved and added to the list to get another transplant to be able to continue to live. The changes recommended could cause her to be removed from the list and loose the chance to continue to thrive.

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,
George B. Hall

George B. Hall
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 personal family friend with a lung transplant patient, who has experienced 10 additional years of life due the the gift of a lung transplant. That person is now been approved and added to the list to get another transplant to be able to continue to live. The changes recommended could cause her to be removed from the list and loose the chance to continue to thrive.

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,
George B. Hall

George B. Hall
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 personal family friend with a lung transplant patient, who has experienced 10 additional years of life due the the gift of a lung transplant. That person is now been approved and added to the list to get another transplant to be able to continue to live. The changes recommended could cause her to be removed from the list and loose the chance to continue to thrive.

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,
George B. Hall

Travis Hall
State of Residence: District of Columbia

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 decisions of life and death should not be made without consulting expert opinion or those whose lives are most directly affected. My dear childhood friend's life was saved due to a double lung transplant, and likely would have had to wait too long had these new rules been in place.

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,
Travis Hall

Amy Lobue
State of Residence: Kentucky

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 friends/loved ones who may not be able to get the life-saving care they need as a result of these changes. I also am a widow of an organ donor, and I know my husband wouldn’t want these changes affecting his legacy and selfless gift.

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 Lobue

Leslie Rojas
State of Residence: Florida

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 [Add your personalized message]

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,
Leslie Rojas

Ellen Bondi
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 My daughter in law is a double lung transplant recipient and is now listed again.

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,
Ellen Bondi

I am not sure if my last comment saved so I am submitting again to make sure my voice is heard. I am the sister and caregiver of a double lung transplant recipient. My sister received her first new set of lungs about 10 years ago, at just 32 years old. My family and I are so grateful for the last decade of time we have had with her, a gift that would have absolutely not been possible without this life-saving surgery. Now my sister is in chronic rejection of her lungs and is re-listed for a second double lung transplant. I am so upset to learn of the new changes made to the lung allocation process, against the unanimous recommendations of experts and the people who will be most effected by these changes. This time around, my sister is at a marked disadvantage for getting new lungs because of the unnecessary changes that have been made, along with many others including children in need of lung transplant. I beg you to please restore the CAS to its previous guidelines, which rightly take into account the special factors that make matching someone up with donor lungs more equitable. Listen to experts, listen to the data, listen to the community you are tasked with serving. People's lives depend on it.
Sincerely, Rachel Garvin

John Spencer Reinewald
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 CAS score is fair to all, there is nothing that is perfect. If all the transplant DR. and hospitals, have agreed with this for several years I believe they would know best for there patience. TRUST YOUR DOCTORS OPINION.

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,
John Spencer Reinewald

Tonia Steed
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 a cherished member of our family is a bilateral lung transplant recipient whose life has been extended 10 years beyond her terminal diagnosis, but who now needs another lung transplant. She has been waiting on this list for a year, and we want to be sure that she and others are allocated life-saving organs with fairness and along previously well-established 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,
Tonia Steed

Tonia Steed
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 a cherished member of our family is a bilateral lung transplant recipient whose life has been extended 10 years beyond her terminal diagnosis, but who now needs another lung transplant. She has been waiting on this list for a year, and we want to be sure that she and others are allocated life-saving organs with fairness and along previously well-established 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,
Tonia Steed

Tonia Steed
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 a cherished member of our family is a bilateral lung transplant recipient whose life has been extended 10 years beyond her terminal diagnosis, but who now needs another lung transplant. She has been waiting on this list for a year, and we want to be sure that she and others are allocated life-saving organs with fairness and along previously well-established 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,
Tonia Steed

Faith Hall
State of Residence: District of Columbia

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 Hello! We have a dear family friend who is a lung transplant recipient and deeply involved in the community. We urge that changes to process. criteria, and adhering to precedent be evidence-based, transparent, and discussed openly in a public forum that allows for dialogue and debate. People’s lives will change depending on how you adjust your rules and adopting protocols internally that require a public comment phase can be invaluable for revealing new good ideas you maybe aren’t thinking about and can maintain good relationships with the community you serve. Please include public comment step.

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,
Faith Hall

Nadya Zawaideh
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 transplant and we live in the pacific northwest. Her CAS dropped due to these changes, even though she has type O blood which makes it harder to find a donor. These changes also negatively impact her since we live in WA state, and by default, most organs will have a longer distance to travel to reach us.

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,
Nadya Zawaideh

Anne Roberts
State of Residence: Montana

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 would not have recieved his life saving lung transplant if these new rules were in place. We were 10 hours away from our transplant center but still made it in time. There are private plane companies that work with people farther away. We can be there in time. That is just one example of how these changes are detrimental to people needing organs. Thank 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,
Anne Roberts

Nicole Wills
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 received a double lung transplant ten years ago and if this had been in place I would have most likely died in the ICU waiting on new lungs.

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,
Nicole Wills

Kari Lusti
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 the former policies and framework prioritized my need for transplant and not the convenience of where my match was located

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,
Kari Lusti

Tricia Lawrenson
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 deeply to me because I am alive today due to a system that prioritized medical urgency.

I was an especially difficult transplant match because of antibodies, in 2008, which significantly limited compatible donor options. After becoming critically ill following the birth of my daughter, at age 25, I required a lung transplant to survive. Years later, I again became critically ill, was placed on a ventilator, and required a second transplant under similarly difficult matching circumstances.

Patients like me are already at an enormous disadvantage because sensitization and antibodies reduce donor compatibility and increase waiting risk. If medical urgency had not remained central to allocation decisions, I may not have survived long enough to receive the organs that ultimately saved my life.

Because of that transplant, I am here today celebrating my daughter’s 18th birthday and watching her walk across the stage at her high school graduation. I am here for the milestones that my daughter and I almost lost forever.

Policies that shift priority away from the sickest and most medically complex patients risk devastating consequences for people like me. While efficiency matters, it should never outweigh survival for critically ill candidates whose circumstances already make transplantation extraordinarily 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,
Tricia Lawrenson

William Goldman
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 I believe that decisions such as revising the Lung Transplan Continous Allocation Score should be fact based.

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,
William Goldman

Tisha Satow
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 transplant and we live in the Pacific Northwest. Her CAS dropped due to these changes, even though she has type O blood which makes it harder to find a donor. These changes also negatively impact her since we live in WA state, and by default, most organs will have a longer distance to travel to reach us.

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,
Tisha Satow

Eva Jurneyt
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 my friend's daughter's name is on the lung transplant list. Needing a solid organ transplant is difficult enough. Having to deal changes to allocation with out a clear discussion of why, and how this occurred is very troubling. It suggests some favoritism and potential foul play. UNOS has worked hard over the years to be clear AND transparent. Why this change 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,
Eva Jurney

William Graf
State of Residence: Kansas

Relationship to Lung Transplant: Brother of 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 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 brother who is on the lung transplant list and want him to have the best chance to receive a 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,
William Graf

Cindy Allen
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 on the waitlist for a double lung 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,
Cindy Allen

TO: hrsa.gov/ optn/policies- bylaws/policy-projects/public-comment-lung-continuous-distribution-polic6#comment-7

I support the Lung Transport Foundation's efforts to revise public policy for fair allocation of lung transplants. My interest in this matter is because a friend's daughter is waiting for a lung transplant in Oregon.
Thank you,
Beth Brody

This comment addresses the OPTN Board’s November 20, 2025 emergency action modifying the Lung Composite Allocation Score (CAS) and calls for its reversal on two distinct grounds.
The first is immediate: the reweighting chose the wrong instrument. Placement efficiency and allocation out of OPTN sequence (AOOS) are real problems, but addressing them by proportionately reducing points assigned to biological disadvantage, pediatric access, waitlist survival, and post-transplant outcomes inflicts an equity cost on candidates the system already recognizes as structurally disadvantaged. The reweighting should be reversed not because efficiency is unimportant, but because this remedy trades away equity to solve an operational problem that better-designed structural reforms can address directly.
The second is structural: this change is the latest in a chain of corrective patches applied to downstream consequences of earlier decisions, rather than a correction of the root design problem. That problem is the absence of an operational window of transplant concept, a mechanism that recognizes transplant benefit is not maximized by transplanting the sickest candidate available, and that beyond a threshold, rising pre-transplant acuity reduces rather than increases post-transplant value.
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I. The Root Pathology
The March 2023 CAS introduced genuine and important advances: a 1:1 equalization of waitlist urgency and post-transplant survival weights, a 5-year post-transplant outcomes horizon, and formal biological disadvantage attributes for height and CPRA. On paper, the 1:1 ratio should have been the most powerful check on acuity runaway since 2005. That it has not arrested escalation is itself informative. The scoring system operates only on listed candidates. It cannot reach the upstream referral decision, the listing threshold, or the community pulmonologist’s evolving sense of when a patient is sick enough to send. Nor can it correct the financial misalignment between bridging procedure reimbursement, which is independent of whether transplantation is achieved, and the outcomes the scoring system rewards. Referral habituation and reimbursement misalignment operate entirely outside the allocation score’s jurisdiction. They explain why acuity runaway persists despite improved score design, and why allocation reform alone cannot fully solve the problem.
Each subsequent policy problem has been treated as isolated and discrete. AOOS is framed as a logistics problem. Blood type O disadvantage is framed as a blood type problem. Geographic inequity is framed as a circle-size problem. In reality, each interacts with the same foundational bias toward late, high-acuity transplantation in an environment with no ceiling on diminishing benefit. Addressing them one by one through score reweighting, each time trading equity for the problem at hand, is a cycle that cannot correct itself.
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II. Geography, the DSA Brake, and a Better Efficiency Reform
The 2017 removal of the DSA as the first allocation unit and its replacement with a fixed 250 NM circle was consequential beyond its stated geographic purpose. The DSA had served an underappreciated function: it acted as an organic brake on acuity runaway. When acuity could only rise within a bounded local donor pool, listing a very high-acuity patient in a low-volume DSA meant accepting a high probability of waitlist mortality before an offer arrived, which imposed discipline on listing decisions that the post-2017 national sharing environment substantially eroded.
The 250 NM circle is also a crude equity instrument, because a fixed radius captures vastly different donor populations across regions of different density. The more coherent reform is a population-adjusted first allocation unit, calibrated to encompass a standardized donor population equivalent based on three years of SRTR deceased donor data for each center’s geography. This produces smaller radii in donor-dense regions and larger radii in donor-sparse regions, improving equity and placement efficiency simultaneously, without requiring biology points to be reduced.
The four structural alternatives to score reweighting for improving efficiency are: a population-adjusted first allocation unit; offer sequencing that formalizes what experienced OPO coordinators already know from the field, namely that certain programs for certain donor profiles will decline and routing offers through them wastes preservation time and degrades organ quality for every subsequent candidate; center- and OPO-level decline accountability through existing OPTN compliance infrastructure; and dyad-level logistics scoring that incorporates organ-specific ischemic time tolerance and candidate-specific physiological compatibility at offer generation rather than distributing that judgment across static listing filters.
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III. ABO Policy and the Cumulative Harm Problem
Shortly after March 2023 CAS implementation, a significant and unanticipated decline in blood type O transplant rates was observed, attributed to removal of ABO-identical priority, which had been underweighted in simulation modeling. The September 2023 correction rescaled blood type O points to 5.0 and improved transplant rates. The November 2025 action then reduced those points to 4.7222, along with CPRA and height points. Once the system has recognized real biological disadvantage and already had to correct an underestimation of blood type O harm, those protections should not be weakened again as the price of solving a different operational problem.
More critically, the cumulative impact of the three sequential ABO changes, March 2023 removal of identical priority, September 2023 partial correction, and November 2025 dilution, has not been modeled together. No published analysis has assessed their compound effect on blood type O transplant probability relative to the pre-CAS baseline. That gap must be closed before any further ABO-related change is made in either direction.
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IV. Process Concern
The Lung Transplantation Committee is reported to have unanimously opposed the November 2025 change. Overriding unanimous expert opposition through an emergency pathway, for a policy then implemented six months later, sets a problematic precedent. An implementation gap of six months is itself evidence the emergency threshold was not met. The twelve-month expiration clause and the public comment process it triggers is the opportunity to correct this.
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V. The Cascade of Acuity Runaway
When the system continuously rewards the most critically ill candidates without a ceiling on diminishing benefit, several downstream effects compound. Referring pulmonologists who observe that moderate-acuity candidates yield no allocation advantage normalize later referral, delaying patients within the benefit window. Patients who wait at high disability accumulate frailty, pulmonary hypertension, and nutritional depletion that are iatrogenic consequences of the system, not their underlying disease. It is further suspected, though difficult to prove without a stable counterfactual, that acuity runaway has reduced cumulative longevity from disease onset to death, that paradoxically transplanting patients pushed beyond the optimal benefit window may have shortened lives the system was designed to extend. Team burnout and operational strain from routinely transplanting extraordinarily ill patients degrades the workforce that serves all candidates.
The ethical dimension is equally important. The normalization of high-acuity transplantation has created tolerance for aggressive pre-candidacy bridging interventions, including ECMO bridging, bariatric surgery, aspiration mitigation procedures, and cardiac interventions, in patients with a low probability of ever achieving successful transplantation. In a fee-for-service environment, these procedures generate substantial institutional revenue independent of whether transplantation is ultimately achieved. The financial incentive is not necessarily the dominant motivation, but it is structurally present and cannot be dismissed as irrelevant to understanding why the threshold for such interventions has drifted lower. Centers habituated to transplanting extraordinarily ill patients begin to define “potentially transplantable” at a threshold that would previously have been considered prohibitive. Interventions with a high probability of futility are then offered to patients and families who, placing profound and legitimate trust in their transplant teams, are not equipped to critically evaluate the cumulative probability of the full trajectory. The moral injury is systemic rather than individual, and the transplant community has an obligation to name it honestly.
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VI. Recommendations
1.    Reverse the November 2025 CAS reweighting and restore prior attribute weights.
2.    If a placement efficiency increase to 15% is retained, fund it exclusively by reducing pediatric priority points from 20.0 to 15.0, restoring all other attributes to pre-November 2025 levels. A pediatric candidate carrying 15.0 points retains a structural advantage insurmountable by any adult candidate at any clinical severity. The reduction is not a diminishment of pediatric access in any practical sense.
3.    Replace the binary pediatric cutoff with an age-graded priority curve tapering from maximum at youngest ages through approximately age 21, eliminating the cliff-edge discontinuity at the 18th birthday and the perverse listing incentive it creates.
4.    Develop a population-adjusted first allocation unit based on donor population density rather than fixed 250 NM radius, restoring a partial organic brake on acuity runaway while improving equity and efficiency.
5.    Formalize OPO field knowledge into offer sequencing logic by incorporating predicted acceptance probability and historical center behavior into the match run, reducing AOOS by aligning algorithmic sequence with clinical and operational reality.
6.    Build dyad-level logistics scoring incorporating organ-specific ischemic tolerance and candidate-specific physiological compatibility at offer generation.
7.    Model cumulative ABO policy impact across all three sequential changes before any further ABO modification.
8.    Retain and strengthen CAS advances: the 1:1 urgency-to-outcomes ratio, the 5-year post-transplant horizon, and the height and CPRA biological disadvantage attributes.
9.    Introduce an operational window of transplant concept into CAS design whereby candidates beyond a projected benefit threshold accrue diminishing priority. An allocation system with no concept of transplanting too late is incomplete and ultimately harmful.
10.   Address the behavioral and financial ecology of acuity runaway directly by advocating to CMS for center-level metrics linking bridging reimbursement to transplant outcomes; commissioning SRTR to publish center-level ratios of bridging procedures to successful transplantation; and requiring informed consent for pre-candidacy bridging to include full sequential probability from procedure to recovery to listing to transplant to meaningful survival, not individual step estimates in isolation.
11.   Mandate prospective public comment for all allocation changes except those meeting a strictly defined emergent public health threshold. A six-month implementation gap is evidence that threshold was not met here.
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VII. Conclusion
The November 2025 reweighting should be reversed. If efficiency gains are nonetheless retained through score adjustment, they should be funded exclusively from pediatric priority points, which remain overwhelmingly dominant even at 15.0, and not from biology, urgency, or outcomes attributes that protect the most vulnerable candidates.
The deeper problem is the absence of a window of transplant concept missing from lung allocation since 2005, compounded by a behavioral and financial ecology recalibrated toward ever-higher acuity and ever-more-frequent bridging procedures without honest accounting from bridging to recovery to listing to transplant to successful transplant. That ecology operates upstream of every allocation formula and beyond the reach of every score reweighting. It is sustained by financial incentives that reward procedural volume regardless of outcome, a referral culture that has normalized the abnormal, and an informed consent environment where patients decide from desperation and trust rather than compound probability. The current comment period is an opportunity not only to correct the November 2025 reweighting, but to begin the harder reckoning the field has owed its patients since long before this band-aid was applied.
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I am an employee of an OPTN member institution, but this comment is submitted in my personal capacity.

As a lung transplant survivor there's some hiccups along the way that can cause patients to reject even if patients lose the weight or do all the treatments that the doctors advice there can still be rejecting. And to be denied a second lung transplant is crazy know the patients is doing everything they can to survive. As a young single mother of 3, what do you tell your kids. To worry what will happen to them when your gone or if they will remember you since they are soo young is heart breaking.

I am writing to strongly oppose implementation of the recent change to the Lung Composite Allocation Score (CAS) points and ratios that was made to address issues with Allocation Out of Sequence (AOOS) and to request the OPTN Board reverse its decision and return to the prior CAS state. AOOS is an issue across all organs and increases when new policies are introduced as it takes time for members of the community to learn and implement a new system. In addition the shifting environment in organ transplantation with ever-increasing numbers of donation after circulatory death and technological advances influence the organ donation and procurement environment. That said, no efforts were made by HRSA to enforce the rules in place to address AOOS and instead pushed to implement changes to the lung CAS system.

Data indicates that AOOS was improving due to higher public scrutiny before this CAS policy change, and based on this, the Lung Committee unanimously voted against changing CAS, favoring instead enforcement of current policy. Data now shows that AOOS has decreased significantly, to pre-CAS levels suggesting that the Lung Committee was, in fact, correct in its assessment. Additionally, the proposed change to CAS is likely to increase waiting list times and wait-list deaths, which should be avoided at all costs. As a transplant physician, our duty is to our patients and to helping as many people in need of a lung transplant to obtain this life-saving treatment.

The OPTN Board should reverse this decision and work with the Lung Committee to further refine lung allocation, allowing the experts in lung transplantation to guide this process. CAS has been a significant improvement, leading to short wait-list times and fewer wait-list deaths, than the previous LAS system, and it can be made even better, if the experts are entrusted to do the job they were elected to do. This policy change does not improve CAS, does not improve AOOS, and only harms patients through increasing the risk of dying while awaiting a lung transplant.

Dr Haytham Elgharably & Dr. Satish Chandrashekaran
State of Residence: Florida

Relationship to Lung Transplant: Surgical and Medical Directors of Lung Transplant Program at Tampa General Hospital

We respectfully urge the HRSA/OPTN Board to reconsider and reverse the decision approved during the November 20, 2025 Board meeting that removed five points from recipient medical urgency categories within the Composite Allocation Score (CAS) and reassigned them to the placement efficiency category. We strongly support restoring the CAS weighting and ratios to the pre-November 20, 2025 structure.

A substantial proportion of lung transplant candidates in the United States are older adults. Approximately 48% of candidates are age 60 years or older, and nearly 9% are age 70 years or older. At the same time, Idiopathic Pulmonary Fibrosis and other fibrotic interstitial lung diseases now account for a growing proportion of lung transplants nationally, representing approximately 35–45% of transplant indications compared with approximately 25–35% for COPD.

This distinction is critically important because fibrotic lung disease has a far more rapid and unpredictable mortality trajectory than COPD. IPF predominantly affects older adults between ages 60 and 70, with a median age at diagnosis of approximately 65 years. The median post-transplant survival for patients with IPF is approximately 4.9 years. Despite somewhat lower long-term survival compared with younger recipients, lung transplantation still provides substantial survival and quality-of-life benefit for these patients.

However, the current CAS framework already places older fibrotic lung disease patients at a disadvantage because predicted long-term post-transplant survival is weighted heavily within the allocation model. As a result, older candidates often receive lower CAS scores despite deriving meaningful benefit from transplantation.

The proposed policy change further compounds this disadvantage by increasing the weighting of placement efficiency from 10% to 15%. The proposed changes may unintentionally decrease organ offers to older recipients with fibrotic lung disease because geographically distant donor offers would receive lower placement efficiency scores within the revised CAS framework. As a result, candidates who may require broader geographic organ sharing to obtain a suitable donor lung could become less competitive in the allocation system, potentially leading to longer waitlist times and increased waitlist mortality for older or medically complex patients.

This concern is especially relevant in states such as Florida, where approximately 22% of the population — more than 5 million individuals — is older than 65 years. As the population ages, the prevalence of fibrotic lung disease will continue to increase, making equitable access to transplantation for older adults an increasingly important national issue.

We recognize and support the OPTN’s goal of improving allocation efficiency and maximizing the overall utility of donor organs. However, allocation systems must also preserve equity and individualized patient-centered decision-making. Older patients with fibrotic lung disease may not demonstrate the same projected long-term survival as younger recipients, yet they still derive substantial survival and quality-of-life benefit from transplantation.

Importantly, transplant programs already have the ability to manage travel-related costs and logistical considerations at the program level. Programs that do not wish to travel long distances for donor procurement can already utilize UNet filters and organ acceptance practices to decline such offers. Therefore, increasing the weighting of placement efficiency within the CAS framework may unnecessarily penalize the broader transplant system and disproportionately disadvantage older patients with fibrotic lung disease who may depend on broader geographic organ sharing to receive transplantation.

Programs willing to pursue donor lungs aggressively and expand access for their waitlisted patients should continue to have the flexibility and ability to do so without being disadvantaged by the allocation system.

For these reasons, we respectfully request that the HRSA/OPTN Board restore the prior CAS weighting structure and reconsider the increased emphasis on placement efficiency to avoid unintended adverse consequences for older patients with fibrotic lung disease awaiting lung transplantation.

Thank you!
Sincerely

Drs Haytham Elgharably & Satish Chandrashekaran

William Simmons
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 have rare genetic mutation that caused my ILD. I almost died waiting for my transplant. If these changes are made patients in my situation will die. DON’T MAKE 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,
William Simmons

Judy Reando
State of Residence: Massachusetts

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 extremely concerned over the possible change in the lung transplant policy. This is very personal to me since my beautiful and brilliant niece has been on the transplant list for a very long time awaiting this life saving surgery. Her chance for living a full life is totally dependent on her standing on the wait list. Taking critical points away from her would make a life saving difference. My niece has been bravely living with her extremely compromised life and limited breath for too long. She courageously fights this battle every day, and she deserves to maintain her current standing on the list.

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,
Judy Reando

Scott Kruse
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 Having received my DLT 2 months ago after a 3.5 year wait, I feel it imperative OPTN process changes require input from experienced transplant medical 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,
Scott Kruse

Dave Bondi
State of Residence: California

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 in law is 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,
Dave Bondi

Willem Wery
State of Residence: Oregon

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 after living with Cystic Fibrosis for 59 years, I'm happy to share that I am now a 7 year survivor of an amazing lung transplant and doing well. I was diagnosed with Cystic Fibrosis as a child at 8 years old. Through treatments, expert medical support, and some good luck, I lived 59 years until the need for a double lung transplant. Thanks to Lung Transplant medical experts, I now continue to live a wonderful life with my wife of 43 years, our 2 adults sons and now 4 grandchildren. The lung transplant patients waiting for lungs today deserve the best and fairest organ allocation system possible as designed and reviewed by the medical experts (the Lung Committee). The changes being implemented under "Emergency" policy change are NOT supported by these experts and have NOT been vetted for feedback or their impact. The reduction in deaths of patients on the lung transplant waitlist utilizing the CAS point system is proof that the experts are improving the process. The unsupported, unvetted, uninformed system redistributing points for unproven "efficiency" (AOOS) should 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,
Willem Wery

Ellen Marie Lipscomb
State of Residence: Virginia

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 daughter will be a lung transplant candidate in the near future and I want to make sure that she is given every fair chance of receiving a pair of new lungs.

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,
Ellen Marie Lipscomb

Anne Fairbrother, DVM, PhD
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 my friend's daughter is on the recipient list. Like many others who require a lung transplant, it is imperative that the criteria used to allocate organs be based on biological need, not ease of transport. The Lung Board professionals were unanimous in their rejection of the proposed changes, and it is not clear why their opinion was dismissed out of hand. Further information from the OPTN Board about why the proposed change will be beneficial to potential recipients is needed. If there is no scientific support for predicting better outcomes, the proposed change should be rejected.

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,
Anne Fairbrother, DVM, PhD

I have been involved with the lung transplant community for over 10 years as a caregiver to my wife who is currently waiting for her second lung transplant. During these 10 years, I have always felt that the medical community had my wife's best interest in mind, but this is no longer the case. On May 7th, when the new allocation scoring went into effect, I watched in horror as her score decreased while her symptoms continue to worsen. This is unacceptable.

OPTN implemented the CAS new system without using adequate scientific modeling available to measure the potential impacts the new policy could have on patient biological factors, wait times and wait list mortality. While you chose to abandon the scientific rigor that these changes demand, these factors were taken into consideration in a soon to be published paper by Dr. Maryam Valapour, et. al, in CHEST (Valapour M, Gunsalus PR, Rose J, Lehr CJ, Baker SL, Dalton JE, Geography as a Determinant of Lung Transplant Access in the United States, Chest (2026), doi: https://doi.org/10.1016/j.chest.2026.05.019). The findings from this research show, after running the new CAS parameters through the modeling, that the amended CAS policy was likely to increase geographic disparities, and significantly more so for high risk candidates with O blood type, with the strongest negative impact affecting people who are listed on the West Coast. The evidence of disparity was not subtle, it was striking. Your new CAS system will put lives at risk, lives that were previously safeguarded under the previous CAS parameters.

In addition, your proposal states that AOOS is the problem and the reason for the CAS change. However, by your own admission, the new CAS system is not expected to “completely alleviate AOOS.” In fact, the OPTN Board has never identified what the goal AOOS rate is, and at what point it becomes a problem. As you know, it is not reasonable to assume that the AOOS rate would ever be zero. And, as Dr Hartwig clearly stated in his presentation before the vote was taken, AOOS had self corrected and was approaching pre 2023 levels. This calls into question why the change in the CAS system was needed in the first place. The HRSA website states that your expected impact is on travel distance, logistical complexity, and policy compliance. It does not escape me that these factors are linked to dollar amounts. Cost. While the Congressional Senate Finance Committee renewed the funding for transplantation, it has changed how the money is allocated and given that task to HRSA. It has occurred to me that HRSA is highly motivated to decrease the cost of organ transport and perhaps has tasked the OPTN board to save money as part of its modernization initiative. If true, I have no problem with creating a more streamlined system, however, making these changes before a new system has been created and scientifically vetted for its human impact makes no sense. This crash and burn approach, or destroying a system before you are ready to replace it, is absurd and reckless and it comes at the expense of human lives.

I ask you to fight with, not against the community that you have been a part of for years. I ask that you stand up for our community, not kowtow to HRSA’s pressure to change the CAS as a prerequisite for green-lighting the transition to Continuous Distribution for other solid organs. Reverse the new CAS scoring system back to its 2025 status and find another way. Fight for our community, not against it. During the OPTN Town Hall meeting, I watched OPTN board members use language such as “this will be a difficult transition.” For whom, I ask? Having my loved one die on the waitlist because of your new unfounded policy is not “a difficult transition.” It is unconscionable, and it is avoidable by using the science that is already available to make informed decisions. My wife's life deserves more than a “wait and see” approach.

In conclusion, I strongly oppose the recent changes to the CAS system which allocates 5 points to the efficiency category by taking away points from biological factors. I’m asking that you reverse your decision and return the CAS system to its previous structure. I’m asking that IF there is a need to change the CAS system in the future, you maintain the 2025 system until you thoroughly run any new scenario through the scientific rigors and medical modeling that this type of decision deserves and that you honor the recommendations made by your medical colleagues and advisory boards. I ask that you take our communities' overwhelming dissent to your new CAS system seriously. A “wait and see” approach to decisions that have life and death implications is totally unacceptable and a complete betrayal to our transplant community. Do the right thing. Change the CAS system back! Do better.

Kathy Wery
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 my husband received a double lung transplant 7 years ago. He would not be alive today without his miracle transplant. I can only imagine that the redistribution of points in the lung allocation system may have been detrimental to his transplant listing, and ultimately receiving his transplant in time for his survival. I feel strongly that the time and effort of the Lung Committee in reviewing, vetting, and supporting the CAS allocation system should remain in place. Let the experts on the Lung Committee evaluate and recommend any enhancements to the CAS scoring. I do not agree with the decision to change the allocation points for AOOS without review and approval of the Lung Committee. Please reverse the OPTN Board 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,
Kathy Wery

Ira Hecht
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 this decision has decreased the probability of favorable patient outcomes.

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,
Ira Hecht

Thank you for the opportunity to provide comment on this vital issue — literally one of life and death — for lung transplant candidates/recipients.

I respectfully urge the Board of Directors of the Organ Procurement and Transplant Network (OPTN) of the Health Resources and Services Administration (HRSA) to return the Continuous Allocation Score (CAS) point allocation and ratios to the pre-November 20, 2025, vote levels. This requires the OPTN Board to reverse the decision it made on November 20, 2025, when it removed five points from categories describing a recipient's medical condition and reallocated them to the efficiency category.

I am calling for this reversal for three reasons:
- First, the entire spectrum of the lung transplant community — professionals, candidates/recipients and their families, and other community members — have consistently and unanimously opposed the Board’s changes to the CAS.
- Second, two nieces of my nieces have cystic fibrosis, and although they have been fortunate not to need a lung transplant so far, if such a need were to arise, the OPTN Board’s decision on November 25, 2025, would adversely affect them.
- Third, beyond my nieces, it’s the right thing to do for all lung transplant candidates/recipients.

Please restore the CAS to its previous point and ratio allocation!

Thank you again for this opportunity to provide comment.
Suzy Pelican

Beth Brody
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 hope the HRSA/OPTN Board will reverse the recent policy decision on the allocation of lung transplants. I support the Lung Transplant Foundation's position on this matter. The issue matters to me because my friend's daughter is having a long wait for a lung transplant in Oregon.

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,
Beth Brody

Edwin I. Brody
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 hope the HRSA/OPTN Board will reverse the recent policy decision on the allocation of lung transplants. I support the Lung Transplant Foundation's position on this matter. The issue matters to me because my friend's daughter is having a long wait for a lung transplant in Oregon.

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,
Edwin I. Brody

On July 31st 2016, at the age of 59, I received a life saving bilateral lung transplant at Brigham & Woman’s Hospital in Boston. I had experienced six years of declining health due to having idiopathic pulmonary fibrosis.
Because of other complicating health issues, I was not considered to be a viable candidate for transplant at the Boston hospitals until early 2016 (I live in the Bangor Maine area, about 250 miles north of Boston).
Now I’m coming up to my tenth “lungaverary” I am very aware of the blessings I have experienced since my transplant; foremost, being able to spend time with my loving family. Being able to be part of my two grandchildren’s lives, ages two and five, is particularly rewarding. I have also been able to return to working part time as a land surveyor.
I fear that if the proposed changes to the CAS are adopted without serious consideration of real data and the input from lung transplant professionals, that others, like myself, would be excluded from the possibility of living meaningful lives as I have been blessed to live.

Patrick Donovan
State of Residence: Maine

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 On July 31st 2016, at the age of 59, I received a life saving bilateral lung transplant at Brigham & Woman’s Hospital in Boston. I had experienced six years of declining health due to having idiopathic pulmonary fibrosis.
Because of other complicating health issues, I was not considered to be a viable candidate for transplant at the Boston hospitals until early 2016 (I live in the Bangor Maine area, about 250 miles north of Boston).
Now I’m coming up to my tenth “lungaverary” I am very aware of the blessings I have experienced since my transplant; foremost, being able to spend time with my loving family. Being able to be part of my two grandchildren’s lives, ages two and five, is particularly rewarding. I have also been able to return to working part time as a land surveyor.
I fear that if the proposed changes to the CAS are adopted without serious consideration of real data and the input from lung transplant professionals, that others, like myself, would be excluded from the possibility of living meaningful lives as I have been blessed to live.

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,
Patrick Donovan

Nancy kent
State of Residence: Washington

Relationship to Lung Transplant: Living Organ Donor

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 feel strongly the OPTN change will negatively impact those who are on the scientifically curated transplant list.

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,
Nancy kent

Elyse Elconin-Goldberg
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 am a bilateral lung transplant recipient. Due to being a smaller-sized person, I require donor lungs that are also smaller in size. Since the majority of organ donors are men, my options are already significantly limited. Lowering the weighting of size-matching factors in the lung allocation process would directly and adversely affect patients like me.

It is critical the HRSA/OPTN Board reverse its decision to alter several factors within the lung allocation score. Prioritizing patients based primarily on geographic proximity to donor organs — even when those individuals may be healthier or have spent less time waiting — risks unfairly disadvantaging patients who live farther away. Such changes could ultimately lead to increased deaths among those on the transplant waitlist who already face limited donor opportunities.

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,
Elyse Elconin-Goldberg

Ravi Prasad
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 believe the care should not be rationed but available to all in need.

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,
Ravi Prasad