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
Dean Nance
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 Please continue to place the need for transplant organ above geography.
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,
Dean Nance
I am urging the Board reverse its November 20, 2025 vote regarding the Lung Transplant Continuous Allocation Score (CAS). Restoring the five points that were removed from the medical condition criteria and reverse the reallocation to the logistical efficiency category are crucial for patients.
This issue is profoundly personal to me. For four agonizing years, my family and I lived under the heavy shadow of progressive Interstitial Lung Disease (ILD). I know firsthand what it means to feel your world shrink as your breath leaves you, and to have your entire survival rest on a medical framework that prioritizes clinical need above all else. Today, I am alive because of a double lung transplant. But I will never forget the vulnerability of the long evaluation period and being on the waitlist. Moving points away from medical urgency to favor "efficiency" shifts the focus from saving the sickest patients to streamlining logistics. When you are fighting progressive ILD, you are fighting for minutes, not days. We cannot allow logistical convenience to outvote a patient's immediate need to survive.
Furthermore, as a survivor, I am deeply troubled by the unprecedented process used to push this policy through. Bypassing public comment protocols and ignoring the unanimous opposition of the Lung Committee without clinical evidence disregards the patients and specialists who ‘live’ in the field. Transitioning from proactive modeling to ‘we’ll fix problems later” seriously risks real lives.
The widespread opposition from the lung transplant community speaks loudly and importantly. I ask that HRSA and the OPTN Board heed the voices of medical professionals, patients and families who have expressed strong opposition. Keep exigency as a priority and restore the CAS to its previous ratios.
Thank you.
The OKBC Lung Transplant Program strongly opposes the recent changes in the CAS score that provide more weight to travel efficiency and proximity.
The 1998 HHS “Final Rule,” adopted in 2000, required organ allocation policies to reduce geographic disparities and prioritize medical urgency, explicitly stating that allocation should not be based on place of residence except when necessary.
The current Lung Composite Allocation Score (CAS), implemented in 2023, intended to improve survival, prioritize the sickest patients, and reduce disparities. However, early experience shows the system relies on subjective weighting rather than validated clinical evidence, and significant concerns about its real-world accuracy have proven justified.
The waitlist survival score is a non-linear function of a patient’s expected days of survival without a transplant. The calculation is based on clinical diagnosis and clinical features that they or may not be relevant to the variety of pulmonary diseases we transplant for. The score ignores or underestimates disease specific features that are relevant to survival in various lung diseases. In addition, the scores do not account for rate of disease progression and other clinically relevant features. Most limiting to the importance of the waitlist survival score is the challenge to get a patient a score that will ‘out-weigh” the geographic proximity points, which you have now increased making it that much more challenging. You often must appeal to an exceptions board that awards or denies additional points with no evidence-based framework or guidelines. Based on our experience with the exception board, it often does not correct the inadequacies of the CAS score, but more often reinforces them and denies exception requests far more frequently than it awards them.
Even more troubling than the waitlist survival score, is the geographic efficiency component—already responsible for a meaningful portion of score variation—that creates structural disadvantages for patients in rural areas. Advances in organ procurement and preservation have made long-distance allocation increasingly feasible, rendering proximity less clinically relevant. Yet the CAS continues to award points favoring closer centers, allowing less-ill patients near urban donor hospitals to outscore sicker patients located farther away. This directly conflicts with the Final Rule’s intent to eliminate geographic bias.
Rural transplant programs are disproportionately harmed, as most donors originate in large urban centers. The current system has already contributed to reduced access and transplant volume in geographically disadvantaged regions. Increasing efficiency points will only amplify these inequities.
The latest “correction to the CAS” of a reallocation of efficiency points will serve only to increase geographic barriers and diminish access to rural populations. Th decision was made despite objections from the OPTN board made up of transplant professionals and without input or comments from the transplant community. It was not based on evolving science of organ procurement and transport, and it was done despite concerns raised by representatives of the transplant clinical community about increasing geographic barriers. The decision clearly did not follow established protocols/policies for changes to the lung allocation system that have been followed in the past.
Data presented at ISHLT shows that the CAS is failing to improve survival compared to the LAS and in fact projected 3-year mortality is worse than under the LAS system. Statistical modeling of the outcomes from the new CAS changes also shows an increase in waitlist mortality. The increased weight on efficiency has only made a flawed system worse, degrading the integrity of the scoring system.
Advancements in procurement and organ transplant have outpaced the evolution of the CAS and without appropriate clinician input into adjustments to the CAS based on current day advances and practices, adjustments in the CAS will likely further degrade the integrity of the scoring system, not enhance it.
We strongly do not support the increase in efficiency (geographic) points. This change is not grounded in current clinical practice or procurement science, and it will further disadvantage rural communities while widening disparities in access to transplantation. We urge reconsideration and a return to policies that prioritize medical urgency and equity over geography and would advocate the elimination of travel and efficacy points altogether, as they do not reflect the state of the art in procurement and preservation that have evolved since the CAS was conceived and implemented.
Thank you for your consideration.
Sincerely,
OKBC Lung Transplant Team
J.J. Schenkelberg
State of Residence: Nebraska
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 It’s important to help those most in need.
Additionally, I share the concerns expressed by the Lung Transplant Foundation letter directed to HRSA and the OPTN Board of Directors, submitted via the Critical Comments and Directives Pathway on April 13, 2026, and signed on to by seventeen distinct lung disease patient advocacy organizations, identifying the following primary concern areas as reasons to oppose this change to the CAS:
- Bucking decades of protocol, no prospective public comment period occurred before this major policy change, and no clinical evidence was supplied justifying the use of the emergency pathway at the time of the vote.
- No clinical rationale was given for ignoring the recommendation of the Lung Committee, which unanimously opposed this change to the CAS, and no solutions were proposed to address the concern that initial modeling suggested that these changes would increase the waitlist mortality for high-risk individuals.
- The change in protocol from extensive modeling before policy changes are implemented to minimal modeling with an intention of catching problems after they occur will endanger lives unnecessarily.
- Patient voices and specialized lung transplant expert opinion should be centered at every stage of OPTN policy development, including the identification of problems, proposed solutions, and the implementation of new policy geared at addressing identified problems.
Thank you again for the opportunity to comment. I sincerely hope that, based on the consistent and unanimous dissent from lung transplant professionals, lung transplant candidates/recipients, and community members, HRSA and the OPTN Board of Directors will reverse the November 20, 2025 vote and restore the CAS to its previous point and ratio allocation.
Sincerely,
J.J. Schenkelberg
Jenna Garwood
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 The changes that have been made put sick patients at higher risk of death and cause them to live in pain and discomfort for far longer than they should have to. Transplant priority should be about taking care of the sickest and most at risk for severe complications not about convenience of transport. Saving lives always involves risk, transport distance should not be a priority.
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,
Jenna Garwood