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
Maria Ochoa Vazquez
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 is a double lung transplant recepient and may need to be listed again in the future.
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,
Maria Ochoa Vazquez
M. S.
State of Residence: California
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 a heart, double lung transplant recipient. Soon after I was placed on the waiting list for a transplant, my health deteriorated very rapidly. My heart and lungs were in such a fragile state, that I had to be admitted to the hospital where I would remain until I received my transplant. My size greatly reduced the chance of finding a suitable donor and I did not have the luxury of time. Fortunately and very gratefully, I received my transplant just in the nick of time. Please do not reduce points for biologically disadvantaged patients or a recipient’s medical condition in favor of placement efficiency.
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,
M. S.
Fidel Oyerbides
State of Residence: Oklahoma
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 feel that the categories describing a recipient's medical condition should be the top priority. That is why we are on the list in the first place. And as our condition worsens, our chances of receiving the organs should increase. I assume none of you on this board are on a donor list or have already had a transplant of any kind. If you are or have, you should realize how important it is to have considered input from transplant doctors or the OPTN thoracic transplant committee. They are the experts. Your decision puts us at a higher risk of death while we are waiting for a 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,
Fidel Oyerbides
I am writing as a lung transplant recipient urging HRSA and the OPTN Board of Directors to reverse the November 2025 decision which both allocated additional points to placement efficiency and increased the weight of the curve in distance based scoring.
I am in significant disagreement with the policy change, the dearth of evidence supporting a correlational link between the implementation of the CAS in its previous form and an increase in AOOS in lung transplant, the validity of the use of the emergency pathway, and how the impact on the lives of lung transplant candidates and recipients is being assessed.
This policy change takes us backwards, ignoring both the results of the Analytic Hierarchy Process used to determine the individual components of the CAS, and the way that the specific components of the CAS and their percentages of points was a direct and thoughtful attempt to make lung transplant allocation more inline with the Final Rule. The values expressed by the lung transplant community have been ignored, and geographic inequality made significantly worse under this policy change (reference: https://pubmed.ncbi.nlm.nih.gov/42176849/ ). If organ transplant truly is a national resource, it should be distributed equally throughout the nation. This policy change works against that goal, significantly disadvantaging transplant hospitals, candidates, and recipients on the West coast. Although it is true that the same number of lung transplants are expected to continue moving forward, they will be differently distributed than they would have been had this policy change not been implemented. For those of us who are living the lives in question, this is not a hypothetical medical ethics exercise. It is whether or not we live or die. And this redistribution of points, because it bypassed the prospective public comment period, not only did not include our voices, but goes against our wishes as determined in the Analytic Hierarchy Process which was used to developed the CAS. In short, this is our medical care, and we did not and do not consent to this.
Additionally, there is no evidence that the current rate of AOOS in lung transplant qualified for a policy change to utilize the Emergency Pathway, and there is significant evidence presented that it does not. Immediately prior to the November vote, Dr. Hartwig presented the OPTN Board with a graph which clearly demonstrated that AOOS in lungs had been around 4% prior to the change to the CAS, had risen steadily in line with other organs for a temporary amount of time, and had essentially returned to the pre CAS level in 2025 without any policy level intervention. Although the years in question, when AOOS was at its highest, included several other significant changes including the invention of new perfusion technologies, and implementation of new OPO metrics, these were not taken into consideration as potential drivers of increased AOOS. Co-occurring is not the same thing as correlational, and HRSA has failed to make a scientifically sound case that the implementation of the CAS with its original point ratios was a significant driver of AOOS. Additional evidence that this policy change should not have qualified under the Emergency Pathway include: the mention during the OPTN Board meeting of an email from HRSA in which HRSA would not allow the Board to continue work on Continuous Distribution in other organ communities unless they voted to implement this policy change in lungs, that that there was a six month delay between the vote and implementation of the policy change, and that HRSA wrote on their own public comment website that they did not expect this change to eliminate AOOS, nor did they list an impact on AOOS under their category of things they did expect it to change.
Many submitted public comments have outlined the potential negative impacts on biologically disadvantaged individuals, and the likely increase in geographic disparity on waitlist mortality. I will not repeat what has already been so thoughtfully contributed to the public comment. But I do want to add that tracking changes in waitlist mortality is not a comprehensive measure of how policy changes create harm in the lung transplant community. Since the public comment window opened, well over four hundred lung transplant candidates, recipients, caregivers, and community members have written in to express their strong opposition to this change. Ignoring our unified voice against this policy causes harm. The increase in fear that we ourselves and our loved ones now live with causes harm. The loss of trust in the independence of the OPTN Board of Directors causes harm. And the fear that decisions will continue to be made moving forward without an appropriately rigorous scientific process causes harm.
Although I do not support this change to the CAS for all of the reasons mentioned above, I do support ongoing evaluation of concerns within lung transplant, rigorous scientific inquiry, and attempts to improve and modernize any aspect of the process that could save more lives and improve transplant outcomes.
Before any new change to the CAS is implemented, I expect to see:
HRSA/OPTN to publicly release what they believe the acceptable rate of AOOS in lung is.
A workgroup assembled that includes the OPO’s working in coalition with other lung transplant professionals to identify all contributing factors to AOOS and working jointly to propose a novel solution free from HRSA’s political influence.
A prospective public comment period once a new proposal is created.
Thank you for the opportunity to comment on this temporary change to the CAS. It is my sincerest hope that the unanimous opposition from the lung transplant community will factor significantly into the final vote when it is time to determined if this policy change will be made permanent.
Henry Verga
State of Residence: California
Relationship to Lung Transplant: Lung 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 this change is less then two years since the last modification in the CAS scoring for lung transplantion, with minimal evidence to support that reducing "logistical complexity" will more effectively allocate donor lung organs for transplant candidates. My double lung transplant was in October 2024 and I am blessed to have received this lifesaving organ 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,
Henry Verga