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
Heather McCoy
State of Residence: South Carolina
Relationship to Lung Transplant: Lung Transplant Candidate/Recipient, Other Solid Organ 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 an organ recipient and know the hurdles it takes to endure this process. I kindly and urgently ask you to reconsider how this decision could affect those of which this policy change taking place would affect an outcome. It should not put only one group at a better chance and negatively affect another. The waiting time is crucial and I waited a month for my lungs. However, I know others who already have longer wait times for different factors. With this decision it could cause the ones that are not as favorable and high priority with this to not get transplanted on time. I have several friends in the Cystic Fibrosis community alone that we do not have any time to waste, unfortunately, we can decline so rapidly that having a better chance at getting organs in our region with the appropriate allocation score can be a matter of success or mortality. The allocation scores as the policy change states being affected and the regions it would favor and not so much, could negatively affect those like myself. Which could turn disastrous and also make statistics for centers who have had success rates so far decline because time is of the essence. The list is long enough and data sometimes does not represent how sick someone truly is. I was one of those during my rejection phase waiting for my second double lung my data did not give a true representation of how close to dying I was. I clung to life knowing my hospital had a shorter wait time in 2012 and 2020 and was thankful I did not have a lot of antibodies to match and was 0+. I also am a petite female so my frame had to be matched with the right size of course and can make it harder to get the right lungs to match the chest cavity. I am thankful my organs came on time or I would not be writing to you today. I am concerned what it could mean for the future and so many in similar positions. As an organ recipient at the end of the day, no one knows what it truly is like to endure this entire process until you find yourselves in these difficult and challenging shoes. I have walked this journey with great courage and hope and want the same to happen for others to experience the beautiful and humbling gift that receiving the gift of life is. I have spoken with other transplant physicians who have told me personally how this could negatively affect regions like my own which a huge population of potential recipients go through. I ask you to please consider if this was you or your loved one what your decision would be. I am deeply concerned how this would affect things moving forward. Although, I have had two lung transplants and a kidney all at my same center at Duke hospital, I wonder how it could affect me if I were to have to get another transplant. The transplant process is hard enough and every day is trying to beat the clock before a life expires so any additional hurdles that can make wait times longer and it harder for lungs to become available in our region will lead to mortality rates going up. The allocation score tied to someone can be a factor of life or death with consideration of priority with receiving lungs. I want to thank you for time and consideration. I am willing to talk with you about my experience further if necessary. I am not in favor of this new policy change and I respectfully ask you all to listen to the transplant community on this matter.
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,
Heather McCoy
I strongly oppose the OPTN’s May 7, 2026 emergency amendment to the lung Composite Allocation Score (CAS), which increased the emphasis on geographic placement efficiency and expanded distance-based scoring.
This amendment was implemented without sufficient deliberation, public comment, or stakeholder consensus, despite explicit opposition from the OPTN Lung Transplantation Committee and significant concerns raised across the transplant community.
Importantly, the amendment undermines the foundational goals of the 2023 continuous distribution framework, which was specifically designed to reduce geographic disparities and prioritize medical urgency, expected benefit, and equitable access to transplantation.
Recent evidence further highlights these concerns. Data published by Valapour et al. (CHEST, 2026) demonstrate that geographic inequities already existed prior to this amendment, with West Coast and certain rural centers having substantially fewer effective donors for hard-to-match candidates. This results in patients in some regions needing to be significantly sicker than those in others to access transplantation—an outcome that directly contradicts OPTN policy stating that organs should be treated as a national resource and that geographic prioritization should be minimized or eliminated.
Additionally, the current scoring system already presents significant barriers for patients with COPD and those of advanced age—populations that make up a large proportion of candidates at many rural centers. By further emphasizing geographic efficiency, this amendment risks compounding existing disadvantages for these patients, thereby exacerbating inequities in access to transplantation.
Equally troubling is the lack of supporting data presented by the OPTN Board to justify these changes, particularly given that such decisions have life-and-death consequences for patients awaiting transplant.
For these reasons, I urge OPTN to rescind this amendment and to ensure that any future changes to placement-efficiency weighting undergo rigorous modeling, transparent impact analysis, and a full public comment process prior to implementation.
Current lung CAS scores are not often reflective of patient level of illness particularly for our ILD patients who scores are generally lower since CAS implementation with this diagnostic category making up one of the largest indications for lung transplant in the current era. Proposed adjustments to the attributes of the score include:
-changing the waitlist survival point ratio to post-transplant outcomes ratio back to 2:1 or even 1.5:1 rather than 1:1
-placing weight not only on resting oxygen need but on ambulatory oxygen requirements as well, and/or allowing for a score adjustment based on center altitude
-adding further distinction between high flow nasal cannula and heated high flow nasal cannulas which can be considered a level of mechanical support, with greater points assigned to heated-high flow
James H Woodruff
State of Residence: Washington
Relationship to Lung Transplant: Friend of Transplant 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 a good friend of mine had a successful double lung transplant due to Cystic Fibrosis. Before the transplant he was struggling with life's most basic activities. Now he's even more active than I am, and enjoying life. I'm so grateful we can share this extra time together. Please REVERSE the CAS change so other lung transplant candidates will have the same opportunity as my friend.
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,
Jim Woodruff
Scott Leibowitz
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 have a friend whose daughter is awaiting a lung transplant, and because I believe that decisions on how organs are allocated should be fair, transparent, primarily aimed at achieving the greatest reductions in mortality, and based on the best available science. I am especially concerned that the current Nov. 20, 2025 allocation system decreases the impact of the height factor, which was shown to reduce wait list mortality, and that this decision was made without any input from the affected lung transplant community.
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,
Scott Leibowitz