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
Sandra Jane Cederbaum
State of Residence: Maryland
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 Lung transplantation is a life or death scenario for my son and those who are waiting and already waitlisted on the lung transplant list. The criteria established reflects decades long evidence based research based on clinical data and outcomes. Life or death, walk in their shoes and make the medically right and morally correct decision by reversing the decision voted on during the 11/20/25 Board meeting.
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,
Sandra Jane Cederbaum
Thank you to the Lung Committee for your continued work on Continuous Development and to the Board for your tireless efforts on the many issues you are addressing, including trying to get the OPTN Committees back to work, hopefully sooner rather than later.
After viewing the video of the Board meeting at which this policy change was passed, I am now aware that (1) the Lung Committee did not agree with the proposed change because they had inadequate time to study its impacts on biologically disadvantaged candidates and pediatric candidates, and AOOS was already declining without this change, and (2) the Board was pressured by HRSA to pass it by communicating that no other organ committees would be allowed to resume their CD work unless and until the Board made these policy changes. While I therefore understand the Board's approval of this policy change, I am disappointed that it reflects HRSA's continued domination over even the new OPTN Board and HRSA's continued disregard for the expertise of the OPTN Board and Committees.
As a very lucky heart recipient who was transplanted with 99% antibodies and type O blood, I am concerned that this policy change not only reduces the weight allocated to biologically disadvantaged (and pediatric) candidates, but increases the weight allocated to "placement efficiency," which doubly disadvantages these candidates since the net needs to be spread wider to find organs to meet these candidates needs. (The only compatible offer I received, after six months inpatient at level 2, was from another state, and came from almost 500 miles away.)
I obviously have no way of knowing what data monitoring has shown since the date of this Board meeting regarding biologically disadvantaged and pediatric candidates, but in general, I disfavor higher allocations to "placement efficiency" and favor higher allocations to biologically disadvantaged and pediatric candidates. I hope the Lung Committee and Board have been closely monitoring the impacts to these candidates and trust that the Committee and Board will ensure that these candidates' opportunities for transplant have not been and will not be not adversely affected.
April Kelli Meade
State of Residence: Maryland
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 do not change the way we receive points for a lung transplant. If it was not for my donor I would still be struggling to breathe. CAS points also saved my life. I got a call within 3c weeks after being listed to receive my lungs. Please do not make all these fighters wait for a life saving procedure. Keep the process the same. Thank you.
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,
April Kelli Meade
This policy change, implemented in May 2026, was approved by the OPTN Board in November 2025 through the emergency action pathway established by OPTN Management and Membership Policy E.7, which states that:
"Policy proposals that meet at least one of the following criteria may be adopted by the Board of
Directors prior to public comment:
• A proposal that is necessitated by a pending statutory or regulatory change.
• A proposal that is required due to an emergent public health issue or patient safety factors.
• A proposal that is necessitated by a new medical device or technology that affects organ allocation."
However, there is no explicit statement explaining which of these criteria the policy meets. Given that "HRSA documented a rise in allocation out of OPTN sequence (AOOS) that correlates with the implementation of the lung Continuous Distribution policy in 2023", I am forced to assume that this is the justification, which arguably falls into the second bullet point above. To my knowledge, this rise in AOOS has only been publicly stated by HRSA, it has not been publicly shown, e.g. HRSA's AOOS Dashboard only shows overall AOOS, not AOOS for lung specifically. HRSA's AOOS Dashboard shows that overall AOOS has dropped substantially in the last 10 months even in the absence of any policy change.
Furthermore, because this policy change was approved through an "emergency" pathway that is not normal, it implies a sense of urgency that should warrant the lack of public comment prior to implementation. However, it took nearly six months to move from OPTN Board approval of this policy change to implementation. By contrast, the last lung allocation policy change began after uncovering errors in SRTR simulation modeling that lead to the initial continuous distribution policy. From the discovery of that error to policy implementation took less than three months, and this included an abbreviated public comment period prior to policy implementation.
Based on the above, I kindly request the OPTN Board answer the following questions for the transplant community:
1. Please provide explicit justification for the use of emergency action to make this policy change.
2. Please publicly provide data showing that AOOS for lung has increased after the initial rollout of continuous distribution, and furthermore publicly provide data showing current AOOS rates for lung.
3. Please explain why it took six months after OPTN Board approval to policy implementation, and furthermore explain whether the initial justification for the emergency pathway still holds.
Regards,
Nicholas L. Wood, PhD
Please do everything in your power to help people with breathing illnesses.