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
Cisca Wery
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 dear brother had a double lung transplant 7 years ago. He was very sick due to Cystic Fibrosis and desperately needed a transplant. He is now thriving. Our mother who recently passed, shared how grateful she was that she didn't lose a second son. My brother and I have been creating new memories together and enjoying time with our families. Please REVERSE the CAS change made so that other Lung Transplant patients have the same opportunity.
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,
Cisca Wery
The American Society of Transplantation (AST) appreciates the opportunity to comment on the proposal, “Update on Lung Continuous Distribution Policy.” AST supports the overarching goals of continuous distribution and the OPTN’s efforts to ensure that lung allocation is fair, transparent, policy-compliant, clinically sound, and operationally efficient. Allocation out of sequence (AOOS) remains an important issue because it may affect patient trust, bypass candidates with priority under OPTN policy, and challenge confidence in the national allocation system. AST therefore supports continued efforts by the OPTN to reduce AOOS, improve compliance with the match run, enhance transparency, reduce avoidable organ nonuse, and optimize the efficiency of lung allocation.
At the same time, AST believes that ongoing evaluation of the current policy changes will be important to ensure they achieve their intended objectives while maintaining appropriate balance among the multiple priorities embedded within the continuous distribution framework. As the transplant community gains additional experience with implementation, continued monitoring and stakeholder engagement will help identify any unintended consequences and inform future refinements as needed.
The proposal notes that HRSA documented an increase in AOOS following implementation of lung continuous distribution in 2023. While this observation appropriately warrants attention, the proposal provides limited information regarding the extent to which the policy changes contributed to the observed trend. AST encourages the OPTN to continue providing transparent, organ-specific data regarding AOOS patterns and the impact of policy modifications so that the transplant community can better understand both the underlying causes and the effectiveness of interventions designed to address them.
The change described in this proposal increases the placement efficiency component of the lung composite allocation score (CAS) from 10% to 15%, with corresponding reductions across other allocation attributes, including waitlist survival, post-transplant outcomes, candidate biology, and patient access. AST recognizes the rationale for improving placement efficiency and reducing logistical complexity in lung allocation. At the same time, ongoing evaluation will be important to better understand how the revised weighting may affect candidate prioritization and access to transplantation across diverse patient populations.
Particular attention should be paid to groups identified during pre-implementation modeling, including pediatric candidates, short-statured candidates, blood type O candidates, highly sensitized candidates, medically urgent candidates, and other populations that may be disproportionately affected by changes in allocation weighting. Early modeling suggested potential reductions in transplant rates for some of these groups, while additional analyses raised questions regarding access and geographic variation.[1] Continued monitoring of these outcomes will help ensure that gains in allocation efficiency are not accompanied by unintended effects on equity, access, or transplant opportunity.
AST also believes additional transparency regarding the development and implementation of these changes would be valuable. Clear communication regarding the basis for policy modifications, the data supporting those changes, and the expected outcomes can help foster stakeholder understanding and confidence. Similarly, regular reporting on post-implementation performance metrics will enable the transplant community to assess whether the intended objectives are being achieved and whether further adjustments may be warranted.
To support ongoing evaluation of these policy changes, AST encourages the OPTN to:
1. Continue reporting lung-specific AOOS data, including trends before and after implementation, stratified by region, OPO, transplant program, candidate characteristics, donor characteristics, offer timing, and organ nonuse.
2. Provide ongoing monitoring of key performance indicators, including waitlist mortality, transplant rates, distance traveled, ischemic time, organ nonuse, exception requests, and AOOS frequency.
3. Report outcomes for potentially impacted populations, including pediatric candidates, blood type O candidates, short-statured candidates, highly sensitized candidates, medically urgent candidates, and other groups affected by disparities or vulnerabilities.
4. Establish and publicly communicate a framework for ongoing policy assessment, including predefined metrics that may warrant further review or refinement if concerning trends emerge.
More broadly, this proposal highlights the importance of maintaining transparency throughout the development and evolution of continuous distribution policy. Continuous distribution was intentionally designed as an adaptable framework that would evolve as real-world experience accumulates. Ongoing refinement should be expected and welcomed; however, the credibility of that process depends on timely reporting of performance metrics, clear communication regarding identified concerns, and meaningful opportunities for stakeholder engagement.
AST believes that allocation policy must continue to balance efficiency with medical urgency, expected outcomes, candidate biology, access, equity, and patient-centeredness. Placement efficiency is an important consideration, particularly for thoracic organs where ischemic time, logistics, center readiness, and rapid offer acceptance are critical. As allocation systems continue to evolve, careful monitoring and data-driven evaluation will help ensure that improvements in efficiency remain aligned with the broader goals of equitable access and optimal patient outcomes.
[1] Valapour M, Gunsalus PR, Rose J, Lehr CJ, Baker SL, Dalton JE, Geography as a Determinant of Donor Access for Lung Transplantation in the United States, Chest (2026), doi: https://doi.org/10.1016/j.chest.2026.05.019.
I was lucky enough to be a Transplant Patient at Durham in 2016.
I can’t say enough about my outcome with the grace of God and these fabulous doctors in Durham.
To see the way, things have been changed, after a doctor has worked centuries on making LungTransplants an Art, with precision, details, and endurance with protocols, why would you manipulate something like that to see multiple accounts of individuals dying because of this new protocol, buy a board at that and not doctors.
Worst idea, I think an individual could come up with a realistic idea.
I think it is 100% a very bad call when it comes to the legitimacy of saving lives. That is what Lung Transplants need, as oppose to more individuals dying, implementing this new program.
I was lucky enough to be a Transplant Patient at Durham in 2016.
I can’t say enough about my outcome with the grace of God and these fabulous doctors in Durham.
To see the way, things have been changed, after a doctor has worked centuries on making LungTransplants an Art, with precision, details, and endurance with protocols, why would you manipulate something like that to see multiple accounts of individuals dying because of this new protocol, buy a board at that and not doctors.
Worst idea, I think an individual could come up with a realistic idea.
I think it is 100% a very bad call when it comes to the legitimacy of saving lives. That is what Lung Transplants need, as oppose to more individuals dying, implementing this new program.
Brandy Hicks
State of Residence: Rhode Island
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 son is tracking toward a lung transplant due to cystic fibrosis. Caregivers and recipients alike deserve fair, balanced and medical analysis when it comes to the waitlist. Any proposed changes should be fully vetted and when SME groups definitively oppose such changes, people need to listen.
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,
Brandy Hicks