Current policy
Every lung transplant candidate receives an individualized lung Composite Allocation Score (CAS). This score determines priority for receiving a lung transplant when donor lung(s) become available. The lung CAS is individual for each candidate and each organ offer. The lung CAS point values represent each of the factors used to match organ offers with transplant candidates (Exhibit 1). The people who have the highest number of points for that organ offer will have the highest priority.
In October 2025, the Health Resources and Services Administration’s (HRSA) preliminary analyses documented a rise in allocation out of OPTN sequence (AOOS) that correlates with the implementation of the lung continuous distribution policy in 2023. In response, the OPTN Board of Directors considered potential changes to lung allocation to promote policy compliance and reduce AOOS.
Note: Certain changes described in this proposal were previously implemented following emergency action by the OPTN Board of Directors and are currently in effect while the proposal proceeds through the formal policy process.
Supporting media
Exhibit 1. Current Lung Composite Allocation Score
| Attribute | Definition | % of Available Points |
|---|---|---|
| Waiting List Survival | Expected 1-year waiting list survival | 25 |
| Post-Transplant Outcomes | Expected 5-year post-transplant survival | 25 |
| Candidate Biology | Total of ABO, CPRA, and height points | 15 |
| ABO | Based on percentage of compatible donors by blood type | 5 |
| CPRA | Based on percentage of compatible donors by CPRA | 5 |
| Height | Based on percentage of compatible donors by height | 5 |
| Patient Access | Total of pediatric and prior living donor points | 25 |
| Pediatric | For candidates under 18 years old | 20 |
| Prior Living Donor | For candidates who donated any organ | 5 |
| Placement Efficiency | Total of travel and proximity efficiency points | 10 |
| Travel Efficiency | Based on impact of distance on costs of travel | 5 |
| Proximity Efficiency | Based on impact of distance on other efficiency (time, availability, etc.) | 5 |
Note. Total Score = Waiting List Survival + Post-Transplant Outcomes + Candidate Biology + Patient Access + Placement Efficiency
Acronyms. ABO=ABO blood group system, CPRA=Calculated Panel Reactive Antibody
Proposed changes
- Increasing the weight on placement efficiency from 10% to 15% of the overall score.
- Reducing the weight on all other parts of the score proportionally, including points assigned to pediatric candidates less than 12 years old for waitlist survival and post-transplant outcomes.
- Replacing the existing travel efficiency and proximity efficiency rating scales with a single placement efficiency rating scale to assign points to potential transplant recipients based on the nautical mile distance between the donor hospital and the transplant hospital.
- Lung CAS scores for all lung and heart-lung candidates on the waiting list will be updated to reflect the changes to the lung CAS (Exhibit 2).
- Approved exceptions will remain in effect based on the percentage of available points approved by the Lung Review Board, and the points assigned for each exception will be reduced proportionately to the adjusted goal weights.
Exhibit 2. Revised Lung Composite Allocation Score
| Attribute | Definition | % of Available Points |
|---|---|---|
| Waiting List Survival | Expected 1-year waiting list survival | 23.6111 |
| Post-Transplant Outcomes | Expected 5-year post-transplant survival | 23.6111 |
| Candidate Biology | Total of ABO, CPRA, and height points | 14.1666 |
| ABO | Based on percentage of compatible donors by blood type | 4.7222 |
| CPRA | Based on percentage of compatible donors by CPRA | 4.7222 |
| Height | Based on percentage of compatible donors by height | 4.7222 |
| Patient Access | Total of pediatric and prior living donor points | 23.6111 |
| Pediatric | For candidates under 18 years old | 18.8889 |
| Prior Living Donor | For candidates who donated any organ | 4.7222 |
| Placement Efficiency | Total of travel and proximity efficiency points | 15 |
Note. Total Score = Waiting List Survival + Post-Transplant Outcomes + Candidate Biology + Patient Access + Placement Efficiency
Acronyms. ABO=ABO blood group system, CPRA=Calculated Panel Reactive Antibody
Anticipated impact
- What it's expected to do
- Reduce median travel distance for lungs
- Reduce logistical complexity in lung allocation
- Improve policy compliance
- What it won’t do
- It will not completely alleviate AOOS.
Terms to know
- Allocation out of OPTN sequence (AOOS): An organ allocation event in which an organ is offered, accepted, and/or transplanted outside the established match sequence.
- Composite Allocation Score (CAS): This score determines priority for receiving a lung transplant when donor lung(s) become available.
- Calculated Panel Reactive Antibody (CPRA): A score (0–100%) indicating the percentage of potential donors a patient is immunologically incompatible with due to antibodies.
Read the full proposal (PDF - 354 KB)
Submit a Comment
Emilio
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 am on the transplant list. I am 23 years old and my life is completely on hold until I can get a lung transplant. This change will likely prolong my time on the waitlist where I have already seen my peers and friends lives progress without me. New jobs, new relationships, new cities, having kids, all while I wait for transplant, unable to work and worsening quality of life as my body degrades. The longer my body has to compensate for my failing lungs the harder it will be to recover from the surgery, it really is so urgent and can not be ignored.
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,
Emilio Ziolkowski
Chelsea Keota
State of Residence: Pennsylvania
Relationship to Lung Transplant: Caregiver/Community Member
Regarding the November 20, 2025 OPTN Board meeting vote to alter the Lung Transplant Continuous Allocation Score (CAS) points and ratios in order to address concerns about Allocation out of Sequence (AOOS).
I am writing to express my strong desire for HRSA/OPTN Board to reverse the decision voted on during the November 20, 2025 Board meeting to remove five points from categories describing a recipient's medical condition and reallocating them to the efficiency category, returning the CAS point allocation and ratios to the pre November 20, 2025 vote levels.
This matters to me because My husband has been patiently waiting for a double lung transplant. He's now waited longer even though his condition may be getting worse. Please reconsider so his call will come sooner. He means everything to me. A transplant will give him a chance to live longer & give us a fighting chance to build the family we've always wanted.
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,
Chelsea Keota
The International Society for Heart and Lung Transplantation (ISHLT) appreciates the opportunity to comment on the OPTN proposal, Update on Lung Continuous Distribution Policy.
While ISHLT supports ongoing evaluation of the lung continuous distribution framework and recognizes the importance of addressing allocation out of sequence (AOOS), the Society does not believe that sufficient evidence has been presented to justify either the policy change itself or the process through which it was adopted. Therefore, we strongly oppose this proposal and do not support continuation or permanent adoption of the policy change in its current form.
**Insufficient Evidence to Demonstrate That Lung Allocation Change is Needed**
Although the intent of the policy change is to reduce AOOS, the number of donors affected by lung AOOS is substantially lower in terms of percentage of donors and total number of donors than kidney or liver donors. , Moreover, it is clear from review of the AOOS graph presented during the provided video of the November 2025 Board meeting that AOOS tracks with policy changes that result in broader sharing rather than specifically as a result of implementation of a CAS allocation mechanism. This is seen with liver allocation where AOOS started to increase following the implementation of Acuity circles in February 2020 and kidney allocation where AOOS started to increase following the removal of DSA from the KAS in March 2021. Finally, it is also clear from the graph that AOOS rates had dropped dramatically by the November 2025 Board meeting; at that time lung AOOS rates had returned to pre-CAS levels. Thus, the AOOS lung allocation “problem” had essentially resolved at the time of the Board meeting, likely explaining why the lung committee voted unanimously to “make no change to lung placement efficiency at this time pending a monitoring period of trends in lung AOOS and identification of drivers of lung AOOS”
**Insufficient Evidence to Support the Change**
The proposal asserts that increasing the weighting of placement efficiency from 10% to 15% will reduce logistical complexity and improve compliance with allocation policy by reducing AOOS. However, the evidence presented does not establish a clear causal relationship between the current weighting structure and AOOS, nor does it demonstrate that the proposed modification will further reduce lung AOOS or prevent it from rising again.
Major allocation policy changes should be supported by rigorous evidence demonstrating both the existence of a problem and the effectiveness of the proposed remedy. ISHLT does not believe that either aspect of that standard has been met.
**Failure to Fully Assess Impact on Patients and Equity**
ISHLT is particularly concerned that additional modeling requested by the Lung Transplantation Committee was not completed prior to implementation.
The proposal moves allocation policy toward greater geographic prioritization by increasing the influence of donor-recipient proximity. Available analyses suggest this change may worsen geographic disparities and adversely affect candidates who already face barriers to transplantation, including blood type O candidates, highly sensitized candidates, candidates with size-matching challenges, and other biologically disadvantaged populations.
These concerns are not theoretical. Continuous distribution was developed, in part, to address the stipulation in the OPTN final rule that a candidate’s place of residence/listing should have the minimum possible impact on access to transplantation. The current policy change may move the system in the wrong direction without sufficient evidence that the anticipated benefits justify that tradeoff.
ISHLT believes that a policy with potentially significant implications for equity and access should not be maintained without a more complete assessment of its consequences.
**Concerns Regarding Use of the Emergency Action Pathway**
ISHLT also has significant concerns regarding use of the emergency action pathway.
The evidence presented publicly does not adequately demonstrate that circumstances warranted emergency action. The emergency pathway was designed to address urgent situations requiring immediate intervention. Based on the information available, ISHLT does not believe sufficient justification was provided to demonstrate that this threshold was met.
Moreover, comments made during the Board's deliberations suggest that broader concerns voiced by HRSA in relation to implementation of CAS for other organs may have influenced the decision-making process. Regardless of intent, the result was implementation of a significant allocation policy change without completion of requested modeling, without the level of evidence normally expected for such a change, and without the opportunity for stakeholder input prior to implementation.
ISHLT is concerned that allowing this approach to stand without challenge may establish a precedent for future allocation policy changes to be implemented through the emergency pathway despite incomplete evidence and limited stakeholder engagement.
**Recommendations**
ISHLT recommends that OPTN:
– Reverse the policy change or at a minimum refrain from taking any further action on the lung allocation policy without providing sufficient evidence to support such changes and receipt of favorable public comment.
– Complete the additional modeling and analyses requested by the Lung Transplantation Committee.
– Conduct further evaluation of the impact on access, equity, geographic disparities, waitlist mortality, transplant rates, and biologically disadvantaged populations.
– Publicly release the results of those analyses.
– Provide an additional public comment period after those analyses are completed and before any decision regarding permanent adoption is considered.
– Develop clearer evidentiary standards and decision criteria governing future use of the emergency action pathway for allocation policy changes.
**Conclusion**
ISHLT supports evidence-based refinement of the lung allocation system and recognizes the importance of improving policy compliance and operational efficiency. However, the Society does not believe that sufficient evidence was presented to justify this policy change, that its potential impact on access and equity was adequately evaluated, or that use of the emergency pathway was appropriately supported.
For these reasons, ISHLT strongly opposes this proposal and urges OPTN to undertake additional analysis, stakeholder engagement, and public review before considering whether these changes should remain part of the lung allocation system.
ISHLT Level of Support: Strongly Oppose
Nikki Brand
State of Residence: Pennsylvania
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 My brother in law has been on the transplant list for over a year and can barely function on the highest setting of oxygen.
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 Brand
Brenda Ellis
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 Please please change this. Your decision lowered my son’s chances of getting his transplant. I have watched him suffer for over 5 years. Do you know how that feels?
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,
Brenda Ellis