Current policy
Every lung transplant candidate receives an individualized lung Composite Allocation Score (CAS). This score determines priority for receiving a lung transplant when donor lung(s) become available. The lung CAS is individual for each candidate and each organ offer. The lung CAS point values represent each of the factors used to match organ offers with transplant candidates (Exhibit 1). The people who have the highest number of points for that organ offer will have the highest priority.
In October 2025, the Health Resources and Services Administration’s (HRSA) preliminary analyses documented a rise in allocation out of OPTN sequence (AOOS) that correlates with the implementation of the lung continuous distribution policy in 2023. In response, the OPTN Board of Directors considered potential changes to lung allocation to promote policy compliance and reduce AOOS.
Note: Certain changes described in this proposal were previously implemented following emergency action by the OPTN Board of Directors and are currently in effect while the proposal proceeds through the formal policy process.
Supporting media
Exhibit 1. Current Lung Composite Allocation Score
| Attribute | Definition | % of Available Points |
|---|---|---|
| Waiting List Survival | Expected 1-year waiting list survival | 25 |
| Post-Transplant Outcomes | Expected 5-year post-transplant survival | 25 |
| Candidate Biology | Total of ABO, CPRA, and height points | 15 |
| ABO | Based on percentage of compatible donors by blood type | 5 |
| CPRA | Based on percentage of compatible donors by CPRA | 5 |
| Height | Based on percentage of compatible donors by height | 5 |
| Patient Access | Total of pediatric and prior living donor points | 25 |
| Pediatric | For candidates under 18 years old | 20 |
| Prior Living Donor | For candidates who donated any organ | 5 |
| Placement Efficiency | Total of travel and proximity efficiency points | 10 |
| Travel Efficiency | Based on impact of distance on costs of travel | 5 |
| Proximity Efficiency | Based on impact of distance on other efficiency (time, availability, etc.) | 5 |
Note. Total Score = Waiting List Survival + Post-Transplant Outcomes + Candidate Biology + Patient Access + Placement Efficiency
Acronyms. ABO=ABO blood group system, CPRA=Calculated Panel Reactive Antibody
Proposed changes
- Increasing the weight on placement efficiency from 10% to 15% of the overall score.
- Reducing the weight on all other parts of the score proportionally, including points assigned to pediatric candidates less than 12 years old for waitlist survival and post-transplant outcomes.
- Replacing the existing travel efficiency and proximity efficiency rating scales with a single placement efficiency rating scale to assign points to potential transplant recipients based on the nautical mile distance between the donor hospital and the transplant hospital.
- Lung CAS scores for all lung and heart-lung candidates on the waiting list will be updated to reflect the changes to the lung CAS (Exhibit 2).
- Approved exceptions will remain in effect based on the percentage of available points approved by the Lung Review Board, and the points assigned for each exception will be reduced proportionately to the adjusted goal weights.
Exhibit 2. Revised Lung Composite Allocation Score
| Attribute | Definition | % of Available Points |
|---|---|---|
| Waiting List Survival | Expected 1-year waiting list survival | 23.6111 |
| Post-Transplant Outcomes | Expected 5-year post-transplant survival | 23.6111 |
| Candidate Biology | Total of ABO, CPRA, and height points | 14.1666 |
| ABO | Based on percentage of compatible donors by blood type | 4.7222 |
| CPRA | Based on percentage of compatible donors by CPRA | 4.7222 |
| Height | Based on percentage of compatible donors by height | 4.7222 |
| Patient Access | Total of pediatric and prior living donor points | 23.6111 |
| Pediatric | For candidates under 18 years old | 18.8889 |
| Prior Living Donor | For candidates who donated any organ | 4.7222 |
| Placement Efficiency | Total of travel and proximity efficiency points | 15 |
Note. Total Score = Waiting List Survival + Post-Transplant Outcomes + Candidate Biology + Patient Access + Placement Efficiency
Acronyms. ABO=ABO blood group system, CPRA=Calculated Panel Reactive Antibody
Anticipated impact
- What it's expected to do
- Reduce median travel distance for lungs
- Reduce logistical complexity in lung allocation
- Improve policy compliance
- What it won’t do
- It will not completely alleviate AOOS.
Terms to know
- Allocation out of OPTN sequence (AOOS): An organ allocation event in which an organ is offered, accepted, and/or transplanted outside the established match sequence.
- Composite Allocation Score (CAS): This score determines priority for receiving a lung transplant when donor lung(s) become available.
- Calculated Panel Reactive Antibody (CPRA): A score (0–100%) indicating the percentage of potential donors a patient is immunologically incompatible with due to antibodies.
Read the full proposal (PDF - 354 KB)
Submit a Comment
As I stated earlier, it seems cruel to change the program that was in place for something that will be detrimental to a large majority of those waiting for lungs and further organs down the road. I truly hope this committee will not just look at the numbers for efficiency sake but to your heart and mind. Consider what this could do if you find yourself or a loved one in a place of needing transplant.
Dear HRSA and OPTN Leadership,
On behalf of the Cystic Fibrosis Research Institute and the cystic fibrosis community members we serve, I write to express our significant concern regarding recent policy actions related to the Composite Allocation Score (CAS) and associated allocation processes. We strongly encourage you to restore the CAS to its previous point and ratio allocation.
As a patient advocacy organization serving those with cystic fibrosis, for whom double lung transplants are often the only life-extending option, we are concerned by the November 2025 vote by the OPTN Board of Directors to change the Composite Allocation Score affecting lung transplant candidates, despite unanimous opposition from the Lung Committee. This policy change was advanced without clear public communication, patient engagement, or implementation guidance, creating uncertainty for patients and transplant centers. We have significant concerns regarding the process, transparency, and timing of these CAS-related changes.
Use of the “Emergency Actions” pathway.
While there did not appear to be a time-sensitive and critical need for immediate change, use of the Emergency Actions pathway led to the bypassing of public comment prior to policy implementation. No clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote to change the CAS. Given the significant impact allocation policy changes have on patients awaiting transplant, we believe a transparent and accessible opportunity for community feedback prior to the adoption of any change is essential.
Alignment with Expert Committee Recommendations
We are concerned that the unanimous recommendations of the OPTN Lung Committee — comprised of clinical experts and community representatives selected specifically for their subject matter expertise — appear to have been overridden. No clinical rationale was given for ignoring the recommendation of the Lung Committee. From the patient perspective, it is difficult to reconcile this outcome when expert guidance and available data suggest that the current priorities, including focus on Allocation Out of Sequence (AOOS), may not reflect the most pressing challenges within lung allocation.
Consideration of the Policy
Recent data from the Scientific Registry of Transplant Recipients website shows Allocation Out of Sequence (AOOS) does not appear to be aligned with the current realities of lung allocation. There is concrete statistical modeling showing that reweighing the allocation of points to the Travel Efficiency category and pulling them away from biological factors such as blood type and short stature, will negatively impact waitlist mortality for lung transplant candidates, particularly among those who are most difficult to match.
Thank you for the opportunity to comment. The Cystic Fibrosis Research Institute and the community members we serve sincerely hope that 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,
Siri Vaeth, MSW
Executive Director
Cystic Fibrosis Research Institute
To the OPTN Board of Directors and the Health Resources and Services Administration:
The Children's Organ Transplant Association represents pediatric transplant patients and their families. We are writing to oppose the November 20, 2025 changes to the Lung Composite Allocation Score and to ask that the prior point allocation be restored.
We want to specifically thank Dr. Rachel Engen for her public comment as a pediatrician. She noted that pediatric candidates have long suffered disproportionate waitlist mortality, that CAS helped close that gap, and that reversing course risks more pediatric deaths on the waitlist. We echo her assessment fully. We would also note that this change disadvantages pediatric candidates twice over: it reduces the points tied to medical need while increasing weight on placement efficiency, which favors candidates who are easier and faster to match, not the harder-to-match children this system exists to protect.
This concern is not ours alone. The Lung Transplant Foundation, joined by seventeen patient advocacy organizations, has noted that the OPTN Lung Committee unanimously opposed this change and that initial modeling suggested it would raise waitlist mortality for high-risk candidates, pediatric patients among them.
This is not only a policy concern. In 2000, Congress amended the National Organ Transplant Act to require the OPTN to consider special issues concerning pediatric patients in allocation policy, and the law still requires a Board seat representing pediatric interests. A change that reduces pediatric weighting, skipped standard modeling and public comment, and was opposed unanimously by the Lung Committee is difficult to reconcile with that mandate.
We ask the Board to reverse the November 20, 2025 decision, restore the prior CAS weighting, and return to the standard modeling and public comment process before any future changes affecting pediatric patients are made.
Thank you for the opportunity to comment.
Respectfully,
Rick Lofgren, President & CEO
Children's Organ Transplant Association
2501 W. Cota Dr. Bloomington, IN 47403
Transplant Families represents pediatric transplant patients and their families. We are writing to oppose the November 20, 2025 changes to the Lung Composite Allocation Score and to ask that the prior point allocation be restored.
We want to specifically thank Dr. Rachel Engen for her public comment as a pediatrician. She noted that pediatric candidates have long suffered disproportionate waitlist mortality, that CAS helped close that gap, and that reversing course risks more pediatric deaths on the waitlist. We echo her assessment fully. We would also note that this change disadvantages pediatric candidates twice over: it reduces the points tied to medical need while increasing weight on placement efficiency, which favors candidates who are easier and faster to match, not the harder-to-match children this system exists to protect.
This concern is not ours alone. The Lung Transplant Foundation, joined by seventeen patient advocacy organizations, has noted that the OPTN Lung Committee unanimously opposed this change and that initial modeling suggested it would raise waitlist mortality for high-risk candidates, pediatric patients among them.
This is not only a policy concern. In 2000, Congress amended the National Organ Transplant Act to require the OPTN to consider special issues concerning pediatric patients in allocation policy, and the law still requires a Board seat representing pediatric interests. A change that reduces pediatric weighting, skipped standard modeling and public comment, and was opposed unanimously by the Lung Committee is difficult to reconcile with that mandate.
We ask the Board to reverse the November 20, 2025 decision, restore the prior CAS weighting, and return to the standard modeling and public comment process before any future changes affecting pediatric patients are made.
Thank you for the opportunity to comment.
Respectfully submitted,
Melissa McQueen, MBA
Executive Director, Transplant Families
A program of the Children's Organ Transplant Association
Carrie Chown
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 received a life saving bilateral lung transplant 22 years ago, just weeks before I would have died without this gift of life. I have been living life to the fullest in honor of my donor and giving back to the lung transplant community as an ambassador and mentor. In this time, I have become friends with many incredible lung recipients, one of which is currently awaiting her second bilateral lung transplant. She has been waiting over a year now, and despite worsening health, has not seen any movement on the list. I am angered and saddened that as she fights for her life, the HRSA/OPTN Board has made it less likely that she will receive her gift in time. This is not about politics or ego, it is about saving human 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,
Carrie Chown