Update on Lung Continuous Distribution Policy

Jodi Norgaard
State of Residence: Illinois

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 family member whose life may very well depend on whether OPTN decides to reverse its recent changes to CAS. For families like mine, this is not an abstract policy issue, it is a matter of opportunity, and ultimately, survival. The decisions made could have life-altering consequences for patients and their loved ones who are relying on a fair and effective transplant system.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Jodi Norgaard

State of Residence: Illinois

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 urging HRSA and OPTN to reverse the recent CAS modification and restore a policy framework that prioritizes human life above all other considerations. Organ allocation policy must be grounded in medical urgency and equity — not geography, institutional politics, or financial incentives.

For those of us with a loved one waiting, this is not an abstract policy debate. It is a matter of survival. Every day on the transplant list carries risk. Every policy decision that disadvantages certain candidates has a direct, human cost.

I respectfully ask that decision-makers listen to transplant patients, their families, and the medical professionals who care for them — and act accordingly.

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.

Thank you for your time and for taking public input seriously.

Grace Norgaard
State of Residence: Illinois

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 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 of my cousin, Carmel, who is awaiting her second 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,
Grace Norgaard

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,
Grace Norgaard

Erica Norgaard
State of Residence: Illinois

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 family member is a double lung transplant recipient and she is currently on the transplant list for a second double lung transplant. Her situation is not hypothetical, it is urgent and ongoing. Removing points from medical severity to prioritize logistical efficiency means that people like her, whose medical need is critical, may be deprioritized in favor of convenience. She has already been through the physical and emotional toll of one transplant, and now her life depends on this system working fairly and transparently. No efficiency gain justifies putting her, or anyone like her, at greater risk.

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,
Erica Norgaard

Jonathan Carlson
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 This matters to me because I have seen how life-changing a lung transplant can be, not only for the patient but for their entire family and support network. As a caregiver and community member, I believe that patients with the greatest medical need should remain the highest priority in the allocation system. Decisions that may increase waitlist mortality for the sickest patients should be supported by strong clinical evidence, transparent processes, and meaningful input from the experts and patient communities most affected. Lives depend on getting these decisions right, and I am concerned that this change moved away from that principle.

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,
Jonathan Carlson

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.

I had a Lung Transplant in 1999 prior to the CAS system, when receiving lungs was purely a function of time on the list and no other priorities. We should not go back in the direction where people’s health status matters less and that’s what we would be doing if we accepted these changes as permanent. As a person of small stature I found it already difficult to get a a transplant. I may someday need to re-transplant as that is always a possibility. I want a fair system based on people’s health and not on proximity to a transplant center, penalizing people in rural areas. As a scientist, I strongly object to changes that are not based on any data, modeling, projections, or input from stakeholders and subject matter experts, but instead are a gut reaction to troubling statistic that has already been mitigated.

Thank you.

Nikki M. Nerhood
State of Residence: New Mexico

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient: Co-Worker's husband

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 Nikki M. Nerhood
State of Residence: New Mexico

Relationship to Lung Transplant: Husband of my co-worker

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 co-worker's husband has been waiting 2-3 years for a lung transplant. They travel to Oklahoma for all his medical appointments while his health gets worse while he waits for a donor. This decision may cause him his life because it will put him further down on the wait 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,
Nikki M. Nerhood

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,
Nikki M. Nerhood

Lee A Taylor
State of Residence: Washington

Relationship to Lung Transplant: Lung Transplant Candidate/Recipient, 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 caregiver for my Sister-In-Law who has had a Bi-Lateral Lung Transplant. These changes may increase waitlist mortality for high risk difficult to match patients. Transplant recipients should be determined based on need, not proximity. Please retain the CAS guidelines to those prior to the November 20, 2025 vote.

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,
Lee A Taylor

Donna L Taylor
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 caregiver for my sister who has received a bi-lateral lung transplant. Transplant recipients should be determined on need, not proximity. Please return to the CAS point allocation prior to the November 20, 2025 vote.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Donna L Taylor

Caroline David
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 received a bi-lateral lung transplant in 2021. I am active is several Lung Transplant Support sites. There are many pre-transplant patients that these changes to the CAS will be negatively impacted. These changes may increase waitlist mortality for patients who are high risk and difficult to match. Please reverse the decision voted on during the November 20, 2025 board meeting and return to the original CAS point and allocation ratios.

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,
Caroline David

Becky Schwartz
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 close personal friend that would have died had she not received 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,
Becky Schwartz

Paloma 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 beloved aunt is now on the list for her second 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,
Paloma Bondi

Decisions such as these are best left in the hands of the specialists who see the results of their efforts daily. A lung transplant is a life-extending, life-changing procedure whose recipients lives must not be relegated to the hands of ill-prepared bureaucrats.

Michael C Huntington
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 am a retired radiation oncologist. I have witnessed how healthcare access in our country is compromised by a lack and stifling of public input and influence upon policy makers at the governmental level. Too often our healthcare policy is determined by ideology and profit-first motives. In this situation of access to needed a lung transplant, it appears that scientific medical opinion is being disregarded and replaced by random decisions related to massive cuts in healthcare funding generally in this country. Please restore the lung transplant allocation criteria that existed prior to 2025. Michael C Huntington MD.

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,
Michael C Huntington

KEVIN TURNER
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 1 year ago today I received my 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,
KEVIN TURNER

Caroline J Zaworski
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 am a kidney donor and a recently retired Palliative Care NP. I am acutely aware of the importance of the appropriate access to needed organs. The Lung Committee has developed the most appropriate criteria for allocation of scarce lung transplants. The decision to change allocation against the recommendations of this committee and without the voice of those most impacted appears to reflect attention to monetary rather than humane principles. I urge you to reconsider your 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,
Caroline J Zaworski

Steve Dona
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 The proposed changes will be detrimental to the Transplant community. Changes such as this will dramatically upset a system that has worked well for decades.

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,
Steve Dona

Michael Wery
State of Residence: New Jersey

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 father had a double lung transplant seven years ago due to Cystic Fibrosis. He is now thriving. I am so happy that he gets to know and love his grandchildren (my kids). We are so grateful for my Dad's lung transplant as he shares his love for the grandchildren in my young and growing family. It is amazing that we have the opportunity to create new, wonderful memories together. 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,
Michael Wery

Foongy Lee
State of Residence: California

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 very disappointed by the prospect of prioritizing efficiency over medical necessity. This seems to me to create a system that could be rife with unethical decisions. It is critical that these decisions are made by medical necessity.

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,
Foongy Lee

I hpope I saved my comment correctly. It is vitally important for this decision to be reversed. Thank you.

Aaeron
State of Residence: Maryland

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 mother lived entire life with one lung and it was astruggle no one should have to endure.

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,
Aaeron

Kate Yablonsky
State of Residence: California

Relationship to Lung Transplant: Transplant Professional

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 concerned about how this will impact the patients we care for at Stanford.

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,
Kate Yablonsky

John Lewis
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 has genetically determined IPF in late stages and needs a pulmonary transplant to live. A missed diagnosis of a lung xray 12 years ago could have made her survival chances better. What we were told last year in Seattle is no longer true however. The lung transplant system is needlessly being messed with by those who have little understanding of the program’s successful history and judicious approach to selecting patients primarily by need.
We had hope and some certainty a year ago. Now we are dismayed, distraught and it is a very stressful time.
Please reverse the new OPTN decision process. It certainly is unfair to many of us in the NW.

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 Lewis

Tina M Fowler
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 son deserves to live. He deserves every opportunity to receive another transplant. He fights harder than anyone I have ever met... and I want him to be around when they find a cure for this horrific disease.

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,
Tina M Fowler

Debra
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 To the HRSA and OPTN Board of Directors,

My name is Debra, and I am writing as a double lung transplant recipient who has been blessed with nearly 24 years of life because of organ transplantation. Every day I have had with my family, children, grandchildren, and loved ones since my transplant has been a gift made possible by a system designed to prioritize medical need and give patients a fair chance at survival.

I am deeply concerned about the recent changes to the Lung Transplant Continuous Allocation Score (CAS) and strongly urge the Board to reverse the November 20, 2025 decision.

As someone whose life depended on a fair and medically driven allocation system, I believe patient need must remain the primary factor when determining who receives a life-saving organ. Policies that place greater emphasis on placement efficiency rather than medical urgency risk disadvantaging the sickest and most vulnerable patients waiting for a transplant.

What concerns me most is that these changes appear to have moved forward despite opposition from lung transplant experts and without the level of public input that such a significant policy change deserves. Decisions that impact life and death should be based on strong clinical evidence, expert consensus, transparency, and meaningful patient involvement.

I know firsthand that behind every number, score, and statistic is a real person fighting to stay alive. There are families praying for more time with a loved one, children hoping for more years with a parent, and patients desperately waiting for the call that could save their life. These individuals deserve a system that prioritizes medical necessity above all else.

For nearly 24 years I have been given the opportunity to live, contribute to my community, and create memories with my family because a donor organ was allocated through a process focused on saving lives. Future transplant candidates deserve that same opportunity.

I respectfully ask the HRSA and OPTN Board to reconsider these changes, restore the previous CAS point allocations, and ensure that patient outcomes, medical urgency, and expert clinical guidance remain at the center of lung transplant policy.

Thank you for your time and for considering the voices of transplant recipients like me whose lives have been directly impacted by these decisions.

Sincerely,

Debra
Double Lung Transplant Recipient
24 Years Post-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,
Debra

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 close friend received the gift of a double lung transplant seven years ago, in 2019. He was diagnosed with Cystic Fibrosis as a child, and after many years of courageously managing the disease, his condition became increasingly severe, leaving him in desperate need of a transplant.

Today, he is thriving. I am incredibly grateful that my family and I have been able to create wonderful new memories with him—experiences that once seemed impossible before his transplant. We enjoy hiking, biking, water skiing, other outdoor activities, and simply spending quality time together with our families. Seeing him live such a full and active life is truly remarkable.

Please reverse these changes so that other lung transplant patients can have the same opportunity to live, thrive, and create lasting memories with the people they love.

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,
Laurie F

Laurie F
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 close friend received the gift of a double lung transplant seven years ago, in 2019. He was diagnosed with Cystic Fibrosis as a child, and after many years of courageously managing the disease, his condition became increasingly severe, leaving him in desperate need of a transplant.

Today, he is thriving. I am incredibly grateful that my family and I have been able to create wonderful new memories with him—experiences that once seemed impossible before his transplant. We enjoy hiking, biking, water skiing, other outdoor activities, and simply spending quality time together with our families. Seeing him live such a full and active life is truly remarkable.

Please reverse these changes so that other lung transplant patients can have the same opportunity to live, thrive, and create lasting memories with the people they love.

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,
Laurie

Dear OPTN Board Members,

I am writing to express my strong opposition to the emergency amendment to the lung Composite Allocation Score (CAS) implemented on May 7, 2026.

I am deeply concerned that this policy change, which increases the weight of geographic placement efficiency, was made without public comment and over the unanimous opposition of the OPTN Lung Transplantation Committee. This shift prioritizes geography over medical urgency and patient health, which directly contradicts the intended goals of the continuous distribution system.

Specifically, I am concerned that:

- The new scoring system reduces points for a patient's health status, potentially resulting in the sickest patients not receiving transplants.
- The increased focus on distance disproportionately harms patients in the West, significantly reducing donor availability for those waiting in California and Washington.
- This change was implemented as an "emergency" without sufficient data or modeling to justify the potential increase in waitlist deaths.

As the family member of someone currently on the lung transplant waitlist, I am personally invested in ensuring that the allocation system remains fair and prioritizes medical necessity over geographic convenience.

I urge the OPTN to revoke the May 7 amendment immediately and return to the standard vetting process, including full modeling and public comment, for any future changes to lung allocation.

Thank you for your time and for reconsidering this critical issue.

Regards,

Dan Suhr

Timothy J Suydan
State of Residence: Massachusetts
Relationship to Lung Transplant: Post Lung Transplant Coordinator

I respectfully urge the HRSA/OPTN Board to reverse the November 20, 2025, decision that shifted five CAS points from recipient medical urgency to the efficiency category and restore the pre-vote allocation weighting.

While improving donor lung transport efficiency is an important goal, the change assumes that ischemic injury is primarily driven by travel distance and time. In reality, advances in lung preservation, including ex vivo lung perfusion (EVLP) and other preservation technologies, have significantly reduced the impact of geographic distance on organ viability by allowing donor lungs to be evaluated, preserved, and transported safely for longer periods.

Under the revised CAS framework effective November 20, 2025, increased weighting toward geographic efficiency could meaningfully influence allocation even when patients share compatible blood type and other matching factors.
For example, a critically ill patient on VA ECMO in Boston with a substantially higher CAS may, in some scenarios, have reduced access to a donor lung located in Arizona if a more clinically stable candidate in Portland, Oregon is geographically closer to the donor hospital. By prioritizing reduced transport distance and cold ischemic time, the updated system may allow geography to more strongly influence offer sequencing, potentially narrowing the advantage of the sickest patients when they are farther from the donor site despite markedly higher medical urgency.

Rather than adjusting allocation weights to favor geographic proximity, OPTN should focus on strengthening the systems that directly improve organ preservation and transport, including expanded EVLP access, investment in preservation technologies, enhanced national coordination, real-time organ tracking, and reimbursement policies that support these advancements.

A more durable solution would also involve systematically evaluating identified barriers, developing clear action plans, and ensuring enforceable accountability across all transplant programs. Instead of relying on incremental “band-aid” policy adjustments, the priority should be addressing root causes through standardized implementation and measurable compliance to ensure consistent, system-wide improvement.

Darlene Lyles
State of Residence: Maryland

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 submitting this comment as a lung transplant candidate being cared for at Johns Hopkins. I have severe connective tissue disease-associated interstitial lung disease and have completed the extensive testing and evaluation process. I have been informed that my results are favorable, and I am now awaiting placement on the transplant list.

This issue matters deeply to me because my future depends on a fair allocation system that prioritizes medical urgency and the needs of the sickest patients. I have worked hard to reach this point, and I know that many patients with advanced lung disease do not have the luxury of time.

I am concerned that recent changes to the Composite Allocation Score (CAS) formula may shift priority away from the sickest and most medically complex candidates. While efficiency and organ utilization are important, they should never outweigh the primary goal of saving lives. Patients with severe lung disease already face tremendous uncertainty, and policies should continue to ensure that medical urgency remains the most important consideration.
As someone who has successfully completed evaluation at Johns Hopkins and is now awaiting listing, I know firsthand how much hope is invested in this process. I respectfully urge OPTN and HRSA to carefully evaluate the impact of these changes and ensure that candidates, recipients, caregivers, and transplant professionals have a meaningful voice in decisions that affect access to life-saving organs.
No patient should be disadvantaged because they are medically complex or critically ill. The transplant system should continue to prioritize those with the greatest need and highest risk of dying without transplantation.

Respectfully,
Darlene Lyles
Maryland
Lung Transplant Candidate, Johns Hopkins Hospital

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,
Darlene Lyles

Megan Bunevich
State of Residence: Texas

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 morals and I believe that people come before money.

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,
Megan Bunevich

Gary Hart
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 I received my miracle lungs 9 years ago today! Not sure how your changes would have affected me but ignoring experts and the transplant community warrants rolling this back.
- 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.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals.

Sincerely,
Gary Hart

Hannah Pfeiffer
State of Residence: Colorado

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I was listed for a lung transplant at 22 years old and am small in stature. It was already so scary knowing that there are limited small lungs for recipients and anything to make that process harder is frightening. I was very lucky my health has increased and I am on pause from being listed but am very likely to be on that list again. Knowing several people who have had their lives saved by lung transplants, this action is very scary and will lead to many unnecessary deaths!!

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,
Hannah Pfeiffer

Joseph Voss
State of Residence: Kansas

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 as a pastor of over 50 years, I have witnessed many lives lengthened through the gift of organ transplants. Currently I have a congregant who has been waiting for two years for a lung transplant. She is becoming very discouraged and fears time is running out for her. Anything that delays the waiting time is a great concern to 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,
Joseph Voss

Location: Oklahoma

Relationship to Lung Transplant: Caregiver and 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 respectfully urge HRSA and the OPTN Board of Directors to reverse the decision made during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocate them to the efficiency category. I ask that the Continuous Allocation Score (CAS) point allocation and weighting be restored to the levels that existed prior to the November 20, 2025 vote.

This issue is deeply personal to me. My mother has spent years battling pulmonary fibrosis, emphysema, and pulmonary hypertension. As her daughter, I have watched her world become progressively smaller as the simple act of breathing has become increasingly difficult. I've attended appointments, helped navigate transplant evaluations, and experienced the uncertainty that comes with knowing a donor organ may represent her only chance at more time with our family.

Because of that experience, I believe the transplant allocation system must always place the greatest emphasis on medical urgency and the likelihood of benefit to the patient. While operational efficiency is important, it should never come at the expense of ensuring that the sickest patients receive the highest priority. Every point within the CAS represents real people, real families, and real lives.

I am equally concerned about the process by which this policy change was adopted. Major changes to a lifesaving allocation system should be transparent, supported by strong clinical evidence, and informed through meaningful public engagement. It is troubling that this change proceeded without a prospective public comment period, without published clinical evidence demonstrating the necessity of using the emergency pathway, and despite the unanimous recommendation of the OPTN Lung Committee opposing the change. When those with the greatest clinical expertise raise concerns about increased waitlist mortality, those concerns deserve to be taken seriously before implementation rather than evaluated after patients may already be affected.

Additionally, I share the concerns expressed by the Lung Transplant Foundation in its April 13, 2026 letter to HRSA and the OPTN Board of Directors, signed by seventeen lung disease patient advocacy organizations. Those concerns include:

* The absence of a prospective public comment period before a significant policy change.
* The lack of clinical evidence supporting the emergency policy pathway.
* The decision to disregard the unanimous recommendation of the OPTN Lung Committee.
* The risk that reducing emphasis on medical urgency could increase waitlist mortality for the highest-risk patients.
* The shift away from comprehensive modeling before implementation toward identifying problems only after patients are impacted.
* The need to ensure that patients, caregivers, transplant recipients, and lung transplant experts remain central participants in every stage of policy development.

The organ transplant system exists because of an extraordinary gift from donor families. Those gifts deserve to be allocated through a process that is transparent, evidence-based, and centered first and foremost on saving the lives of those in greatest medical need. As someone whose family has lived through the uncertainty of advanced lung disease and transplant evaluation, I respectfully ask the Board to restore the previous CAS weighting while continuing to study solutions to Allocation Out of Sequence through a collaborative, evidence-driven process.

Thank you for your consideration and for your commitment to improving the nation's transplant system. I hope the HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the previous CAS point allocation and ratios.

Sincerely,

Megan Butler

As a double lung transplant patient I know that the old CAS system works. I was at the end stage of my IPF and would not be here to respond today. If I had been under the new criteria, I would have succumb to IPF.

I want to express my strong opposition the OPTN’s May 7, 2026 emergency amendment to the lung Composite Allocation Score (CAS), which increased the weight of geographic placement efficiency and strengthened distance-based scoring.

This amendment was implemented without adequate deliberation, public comment, or consensus, AND despite opposition from the OPTN Lung Transplantation Committee and concerns from the transplant community.

The amendment reverses the goals of the 2023 continuous distribution system, which was designed to reduce geographic disparities and prioritize medical urgency, expected benefit, and equity.

Moreover recent studies have provided data (Valapour and colleagues. 2026 CHEST) that demonstrate geographic disparities already existed before the amendment, with West Coast centers and some rural centers having much lower effective donor numbers for hard to match recipients- which means that patients in some regions of the country have to be sicker than in other regions of the country to access organs. This is in direct conflict with the OPTN’s own policy which states
“organs should be considered a national, rather than a local or regional, resource. That is, geographical priorities in the allocation of organs should be prohibited.”

Equally concerning is that the OPTN board presented no data to justify these changes and their decision come at the expense of patients lives.

I urge OPTN to revoke the amendment and require any future changes to placement-efficiency weighting to undergo full modeling, transparent impact analysis, and public comment before implementation.

Julia Klesney-Tait
Medical Director University of Iowa

I want to express my strong opposition the OPTN’s May 7, 2026 emergency amendment to the lung Composite Allocation Score (CAS), which increased the weight of geographic placement efficiency and strengthened distance-based scoring.

This amendment was implemented without adequate deliberation, public comment, or consensus, AND despite opposition from the OPTN Lung Transplantation Committee and concerns from the transplant community.

The amendment reverses the goals of the 2023 continuous distribution system, which was designed to reduce geographic disparities and prioritize medical urgency, expected benefit, and equity.

Moreover recent studies have provided data (Valapour and colleagues. 2026 CHEST) that demonstrate geographic disparities already existed before the amendment, with West Coast centers and some rural centers having much lower effective donor numbers for hard to match recipients- which means that patients in some regions of the country have to be sicker than in other regions of the country to access organs. This is in direct conflict with the OPTN’s own policy which states
“organs should be considered a national, rather than a local or regional, resource. That is, geographical priorities in the allocation of organs should be prohibited.”

Equally concerning is that the OPTN board presented no data to justify these changes and their decision come at the expense of patients lives.

I urge OPTN to revoke the amendment and require any future changes to placement-efficiency weighting to undergo full modeling, transparent impact analysis, and public comment before implementation.

I am submitting this comment to object to the OPTN Board’s emergency action on May 7, 2026, modifying the Lung Composite Allocation Score (CAS) to place greater emphasis on placement efficiency and geographic distance in lung allocation decisions.

The amendment was adopted through an expedited process that bypassed the analysis, public engagement, and consensus-building typically expected for changes with significant consequences, despite concerns raised by members of the OPTN Lung Transplantation Committee and numerous stakeholders.

By increasing the influence of geographic factors, the policy departs from the intent of the continuous distribution system implemented in 2023, which was designed to balance medical urgency, transplant benefit, patient access, and fairness while reducing reliance on arbitrary geographic boundaries.

Published data also call this approach into question. In a 2026 CHEST publication, Valapour et al. reported substantial variation in donor access across regions, particularly affecting West Coast programs and certain rural centers caring for candidates who are more difficult to match. As a result, similarly situated patients may face different thresholds for receiving an organ based solely on location, and increasing the weight of geographic efficiency may worsen rather than reduce these disparities.

This approach also appears difficult to reconcile with the OPTN Final Rule, which states:

“Organs should be considered a national, rather than a local or regional, resource. That is, geographical priorities in the allocation of organs should be prohibited.”

Moreover, no publicly available evidence was presented showing that the amendment would improve survival, reduce waitlist deaths, or enhance transplant outcomes. Changes affecting access to scarce, life-saving organs should be supported by transparent analyses and robust modeling; without such evidence, the policy risks unintended harms and disproportionate burdens on patients who already face barriers to transplantation.

For these reasons, I respectfully request that the OPTN rescind the emergency amendment and subject any future revisions to placement-efficiency weighting to a full evaluation process, including modeling, impact analyses, stakeholder input, and public comment. Organ allocation policy should be guided by evidence, transparency, and equitable national access for all transplant candidates.

I want to express my strong opposition the OPTN’s May 7, 2026 emergency amendment to the lung Composite Allocation Score (CAS), which increased the weight of geographic placement efficiency and strengthened distance-based scoring.

This amendment was implemented without adequate deliberation, public comment, or consensus, AND despite opposition from the OPTN Lung Transplantation Committee and concerns from the transplant community.

The amendment reverses the goals of the 2023 continuous distribution system, which was designed to reduce geographic disparities and prioritize medical urgency, expected benefit, and equity.

Moreover recent studies have provided data (Valapour and colleagues. 2026 CHEST) that demonstrate geographic disparities already existed before the amendment, with West Coast centers and some rural centers having much lower effective donor numbers for hard to match recipients- which means that patients in some regions of the country have to be sicker than in other regions of the country to access organs. This is in direct conflict with the OPTN’s own policy which states
“organs should be considered a national, rather than a local or regional, resource. That is, geographical priorities in the allocation of organs should be prohibited.”

Equally concerning is that the OPTN board presented no data to justify these changes and their decision come at the expense of patients lives.

I urge OPTN to revoke the amendment and require any future changes to placement-efficiency weighting to undergo full modeling, transparent impact analysis, and public comment before implementation.

I strongly oppose the OPTN’s May 7, 2026 emergency amendment to the lung Composite Allocation Score (CAS), which increased the weighting of geographic placement efficiency and strengthened distance-based scoring.
This amendment was enacted without adequate deliberation, public comment, or consensus, despite clear opposition from the OPTN Lung Transplantation Committee and significant concern expressed by the transplant community. Implementing such a consequential change through an emergency process undermines transparency and stakeholder trust.
The amendment directly contradicts the intent of the 2023 continuous distribution framework, which was developed to reduce geographic disparities and to prioritize medical urgency, expected benefit, and equity in organ allocation.
Importantly, recent evidence demonstrates that geographic disparities already existed prior to this amendment. Data published by Valapour and colleagues (CHEST, 2026) show that West Coast centers and some rural programs had substantially lower effective donor availability for hard-to-match recipients. This means that patients in certain regions must be significantly sicker than those in other regions to access transplantation. These findings are fundamentally inconsistent with OPTN policy, which states that organs should be considered a national—not local or regional—resource and that geographic priorities in allocation should be prohibited.
Equally troubling, the OPTN Board presented no data to justify these changes, despite the clear risk that such policy shifts may worsen inequities and adversely affect patient survival.
For these reasons, I urge the OPTN to revoke the May 7, 2026 amendment. Any future changes to placement-efficiency weighting should be subject to rigorous modeling, transparent impact analyses, and full public comment prior to implementation.
Sincerely,
Kal Parekh

Mary Gregoire
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 close friend had 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,
Mary Gregoire

James Carson
Oklahoma
Relationship to Lung Transplant: 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 and the OPTN Board of Directors 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 reallocate 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 mother is living with pulmonary fibrosis, emphysema, and pulmonary hypertension and has undergone evaluation for lung transplantation. My friend, who is also the caregiver for her mom, has told me how devastating advanced lung disease can be and how much patients and families depend on a fair allocation system that prioritizes medical need, every day matters when someone is struggling to breathe.
I am deeply concerned by a policy change that appears to place greater emphasis on efficiency metrics than on the biological and medical factors that reflect a patient's urgency and risk. Families facing the possibility of transplantation deserve confidence that donor lungs will be offered first based on who needs them most, not on logistical convenience.
I am also troubled by the process used to enact this change. The lack of a prospective public comment period, the absence of supporting clinical evidence justifying the emergency pathway, and the decision to move forward despite unanimous opposition from the OPTN Lung Committee undermine confidence in a policy that could directly affect patient survival. Patients, caregivers, transplant recipients, and transplant professionals deserve to have their voices heard before changes of this magnitude are implemented.
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 these changes would increase waitlist mortality for high-risk individuals.
• The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with the 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 and recipients, caregivers, 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,
James Carson

As a family member of a person who received a DLT and anticipating one myself, I must express concern about the changes to the allocation process. First, the changes weren't done by the usual manner, incorporating various inputs of experts and key stakeholders. Secondly, the CAS scoring that was previously implemented was showing an improvement in deaths on the waiting list.
Please open up the process to the entire committee and reconsider the changes you have proposed. These proposed changes reflect too great an emphasis on efficiency and economics, while minimizing consideration of other factors that make it difficult to find suitable donors.
At the very least, please reassure the lung transplant community that the process is open, transparent, and inclusive.
Thank you.

Michael McCormick
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 seen the power of lung transplants to save lives and want to ensure equity in that process. My brother-in-law received a bi-lateral lung transplant about 3 years ago. Absent that transplant, he would be dead today. Instead, he brings joy to the life of my sister, his son and daughter-in-law, his extended family and his community.
I now volunteer with a lung transplant support group and see the hope and, sometimes joy(presuming a successful transplant), this process can bring to hundreds of people in my community and thousands around the U.S.
The change from the LAS to the CAS & CD was a watershed in improving the PROCESS to help ensure INCREASED and equitable transplant allocation. This arbitrary and capricious change by the OPTN board is a misguided attempt to simply and BLINDLY "do something", even if it's wrong, even if it doesn't cure what it's supposed to and EVEN IF THERE IS NO REAL PROBLEM!
I watched the meeting where this change was adopted and was aghast at the sloppy and arbitrary manner in which the potential change was discussed, modified in a slap-dash, uneducated, and incomplete fashion and then rushed through approval by the Board Chair. All done OVER the advice of a UNANIMOUS recommendation of the lung transplant experts AND after acknowledging that the problem this was intended (AOOS) to fix was, for all intents, gone insofar as lung transplant was concerned. All because of a BLIND edict from HRSA that would hold CD hostage for ALL OTHER ORGANS (despite its overwhelming success for lungs) "unless a policy change was made." A responsible board would have pushed back on HRSA.
And this was done in the name of "efficiency"? To save a few bucks. Never mind that the organ transportation cost is a small fraction of the overall care, that CHANGES in distance would have a trivial impact or no impact or a positive one on costs), the hand-waving used to equate "distance" with "cost". Never mind the noted potential increase in waitlist mortality (to say it's "not statistically significant" doesn't mean it isn't real, only that it isn't proven), the projected INCREASED DEATHS for pediatric patients. Never mind that NO case was made, not one shred of evidence presented to denote this as an emergency, the only possible justification for this change. etc. etc. The folly beggars belief.
The board showed only privilege and hubris in making this policy change and turned their backs on the thousands of patients awaiting transplant and their families, the donors and their families as well as the thousands of medical professionals who work day and night tirelessly to save lives only to have the rug pulled out from under them.
It might be just a case of foolish administration if not for the real lives involved. That makes it a tragedy.

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,
Michael McCormick

Cristine Vreeman
State of Residence: Minnesota

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 mother in law received a double lung transplant. The CAS points allowed her to be placed at a level of high importance to receive a donation. After surgery, the surgeon informed her that the condition her lungs had been in, he was surprised she had made it as long as she did, and she made it just in time. Changing the CAS point system to remove specific medical characteristics could have meant she would not have been a recipient. We need to listen to the medical experts on what characteristics should weigh in to this point system.

Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:

- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.

Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.

Sincerely,
Cristine Vreeman

Devin Wakefield
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 close friend of several lung transplant recipients and am writing to express my alarm and deep displeasure at this rule change. I highly respect my lung transplant recipient friends who universally are alarmed and displeased by this change. I also know several people on the transplant list who feel this change will make it harder to get a transplant. Please listen to the community who does not like this change, and decry the overruling of the advisory board. The advisory board know this best and we all feel they should have been listened to.

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,
Devin Wakefield

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 change is concerning and important to me because my friend, who is on the wait list for a second lung transplant, and many others' lives will be put at a greater risk.
I urge you to listen to the Lung Committee, expert opinion of lung transplant professionals as well as the voices of patients, their families and friends.
Thank you for giving me this opportunity to express my grave concern regarding this change.

Tom Swinford
State of Residence: Colorado

Relationship to Lung Transplant: Caregiver/Community Member

Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).

I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.

This matters to me because I have a very good friend with Cystic Fibrosis. Seven years ago, he was on oxygen 24 hours a day, and his activities were largely limited to moving around his own home. Without a lung transplant, he had no chance of enjoying physical activities like water skiing, which we had regularly done together in the past.

Thanks to a successful double lung transplant, he experienced an extraordinary recovery. He regained his active life and is now a vibrant, energetic 66 year old. Today he walks daily, snow skis in the winter, and in the summer he kayaks, wake surfs, and even water skis again. I am incredibly grateful to have my friend back, and we are once again able to enjoy the outdoor activities we love.

Please reverse the CAS change so that more people awaiting lung transplants can have the same life changing 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,
Tom Swinford

Lucinda Taylor
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 am very concerned about the recent changes to the CAS. This arbitrary change without opportunity for important feedback from patients, lung transplant professionals, such as the Lung Transplant Committee, along with the voices of patients, family and friends is alarming. I have a friend who is on the wait list for a second lung transplant. This change dramatically decreases her chance of receiving a timely transplant and puts her at great risk.

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,
Lucinda Taylor