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
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
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
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.
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