Item 1A Risk Factors 17
Item 1B. Unresolved Staff Comments 33
Item 2. Property 33
Item 3. Legal Proceedings 34
Item 4. Mine Safety Disclosures 34
PART II
Item 6. [Reserved] 35
Item 7A. Quantitative and Qualitative Disclosure About Market Risk 46
Item 8. Financial Statements and Supplementary Data 46
Item 9A. Controls and Procedures 47
Item 9B. Other Information 47
Item 9C. Disclosure Regarding Foreign Jurisdictions that Prevent Inspections 47
PART III
Item 10. Directors, Executive Officers, and Corporate Governance 48
Item 11. Executive Compensation 48
Item 14. Principal Accountant Fees and Services 48
PART IV
Item 15. Exhibits and Financial Statement Schedules 49
i
FORWARD-LOOKING
STATEMENTS
This
Annual Report on Form 10-K (this “Form 10-K”) of PAVmed Inc. (“we”, “us”, “our” or “PAVmed”
or the “Company”), contains forward-looking statements that involve substantial risks and uncertainties. All statements,
other than statements of historical facts, contained in this Form 10-K, including statements regarding our future results of operations
and financial position, business strategy and plans and objectives of management for future operations, are forward-looking statements.
The words “may,” “will,” “should,” “expects,” “plans,” “anticipates,”
“could,” “intends,” “target,” “projects,” “contemplates,” “believes,”
“estimates,” “predicts,” “potential” or “continue” or the negative of these terms or
other similar expressions are intended to identify forward-looking statements, although not all forward-looking statements contain these
identifying words. Forward-looking statements are not guarantees of future performance and the Company’s actual results may differ
significantly from the results discussed in the forward-looking statements. Factors that might cause such differences include, but are
not limited to, those discussed in Item 1A of Part I of this Form 10-K under the heading “Risk Factors,” which are incorporated
herein by reference.
Important
factors that may affect our actual results include:
● our limited operating history;
● our financial performance, including our ability to generate revenue;
● the ability of our products to achieve market acceptance;
● our potential ability to obtain additional financing when and if needed;
● our ability to protect our intellectual property;
● our ability to complete strategic acquisitions;
● our ability to manage growth and integrate acquired operations;
● the potential liquidity and trading of our securities;
● our regulatory and operational risks;
● cybersecurity risks;
● risks related to the COVID-19 pandemic; and
In
addition, our forward-looking statements do not reflect the potential impact of any future financings, acquisitions, mergers, dispositions,
joint ventures or investments we may make.
We
may not actually achieve the plans, intentions, and/or expectations disclosed in our forward-looking statements, and you should not place
undue reliance on our forward-looking statements. You should read this Annual Report on Form 10-K and the documents we have filed as
exhibits to this Annual Report on Form 10-K completely and with the understanding our actual future results may be materially different
from what we expect. We do not assume any obligation to update any forward-looking statements, whether as a result of new information,
future events or otherwise, except as required by applicable law.
ii
PART
I
Item
1. Business
Background
and Overview
PAVmed
is a highly differentiated, multi-product, commercial-stage medical technology company organized to advance a broad pipeline of innovative
medical technologies from concept to commercialization, employing a business model focused on capital efficiency and speed to market.
Our
current central focus is predominantly on commercial expansion and execution including the acceleration of EsoGuard and Veris Cancer
Care Platform commercialization. As resources permit, we will continue to explore internal and external innovations that fulfill our
project selection criteria without limiting ourselves to any target specialty or condition. More broadly, we strive to maintain balance
within our pipeline with shorter-term, lower-risk projects with the prospect for rapid commercialization and revenue generation supporting
development of longer-term projects. At the same time, we are continuously re-assessing each project’s long-term commercial potential
relative to other projects in our pipeline, accelerating or decelerating the project and reallocating resources accordingly.
The
Company operates in one segment as a medical technology company, with the following lines of business: Diagnostics, Medical Devices
and Digital Health. Below is a summary of each of our key products within these sectors, including in particular EsoGuard and the
Veris Cancer Care Platform, currently our two leading products. We are also pursuing a number of research and development project
and product opportunities across these three lines of business, which have either been developed internally or have been presented
to us by clinician innovators and academic medical institutions for consideration.
EsoGuard
and EsoCheck
We
believe that the flagship product of our majority-owned subsidiary Lucid Diagnostics Inc. (Nasdaq: LUCD) (“Lucid”), the EsoGuard
Esophageal DNA Test, performed on samples collected with the EsoCheck Esophageal Cell Collection Device, constitutes the first and only
commercially available diagnostic test capable of serving as a widespread screening tool to prevent esophageal adenocarcinoma (“EAC”)
deaths, through early detection of esophageal precancer in at-risk gastroesophageal reflux disease (“GERD,” also commonly
known as chronic heartburn, acid reflux or simply reflux) patients.
EsoGuard
is a bisulfite-converted next-generation sequencing (NGS) DNA assay performed on surface esophageal cells collected with EsoCheck. It
quantifies methylation at 31 sites on two genes, Vimentin (VIM) and Cyclin A1 (CCNA1). The assay was evaluated in a 408-patient multicenter
case-control study published in Science Translational Medicine and showed greater than 90% sensitivity and specificity at detecting esophageal
precancer and all conditions along the BE-EAC spectrum, including on samples collected with EsoCheck (Moinova, et al. Sci Transl Med.
2018 Jan 17;10(424): eaao5848). EsoGuard is commercially available in the U.S. as a Laboratory Developed Test (LDT) performed at our
CLIA-certified laboratory. Cell samples, including those collected with EsoCheck, as discussed below, are sent to our laboratory for
testing and analyses using our proprietary EsoGuard NGS DNA assay.
EsoCheck
is an FDA 510(k) and CE Mark cleared noninvasive swallowable balloon capsule catheter device capable of sampling surface esophageal cells
in a less than five-minute office procedure. It consists of a vitamin pill-sized rigid plastic capsule tethered to a thin silicone catheter
from which a soft silicone balloon with textured ridges emerges to gently swab surface esophageal cells. When vacuum suction is applied,
the balloon and sampled cells are pulled into the capsule, protecting them from contamination and dilution by cells outside of the targeted
region during device withdrawal. We believe this proprietary Collect+ProtectTM technology makes EsoCheck the only noninvasive esophageal
cell collection device capable of such anatomically targeted and protected sampling.
EsoGuard
and EsoCheck are based on patented technology licensed by Lucid from Case Western Reserve University (“CWRU”). EsoGuard and
EsoCheck have been developed to provide an accurate, non-invasive, patient-friendly screening test for the early detection of adenocarcinoma
of the esophagus (“EAC”) and Barrett’s Esophagus (“BE”), including dysplastic BE and related pre-cursors
to EAC in patients with chronic gastroesophageal reflux (“GERD”).
Market
Opportunity
In
2023, approximately 20,000 U.S. GERD patients are projected to be diagnosed with EAC and approximately 16,000 will die from it. Over
80% of EAC patients will die within five years of diagnosis, making it the second most lethal cancer in the U.S. The U.S. incidence of
EAC has increased 500% over the past four decades, while the incidences of other common cancers have declined or remained flat. In nearly
all cases, EAC silently progresses until it manifests itself with new symptoms of advanced disease. EAC is nearly always invasive at
diagnosis, and, unlike other common cancers, mortality rates are high even in its earlier stages.
As
discussed below under the heading “Clinical Guidelines for At-Risk Population”, the American Gastroenterology Association
(“AGA”) recently significantly expanded the target population for esophageal precancer screening, recommending screening
in at-risk patients without symptoms of GERD. Based on this revision, we believe the cohort recommended for screening consists of an
estimated 30 million U.S. individuals with at least 3 established risk factors for BE. Accordingly, we believe EsoGuard’s total
addressable U.S. market opportunity exceeds $60 billion based on an effective Medicare payment of $1,938 and the estimated 30 million
U.S. patients recommended for screening by clinical practice guidelines. (In December 2019, we secured “gapfill” determination
for EsoGuard’s PLA code 0114U through the CMS CLFS process. This allowed us to engage directly with Medicare contractor Palmetto
GBA and its MolDx Program on CMS payment and coverage. In October 2020, CMS granted EsoGuard final Medicare payment determination of
$1,938.01, effective January 1, 2021.)
Unfortunately,
for a variety of reasons, less than 10% of at-risk patients who are recommended for screening undergo traditional invasive upper gastrointestinal
endoscopy (EGD). We believe that the profound tragedy of an EAC diagnosis is that likely death could have been prevented if the at-risk
patient had been screened and then undergone surveillance and curative endoscopic esophageal ablation of dysplastic BE.
Since
mortality rates are high even in early stage EAC, preventing EAC deaths requires detection and intervention at the precancer stage. Most
of the necessary elements for such an early detection program are already well established—an at-risk population (at-risk GERD
patients), a precancer (BE), and an intervention which can halt progression to EAC (endoscopic esophageal ablation). The only missing
element for such an early detection program is a widespread screening tool that can detect BE prior to EAC.
We
believe EsoGuard, used with EsoCheck, constitutes that missing element—the first and only commercially available diagnostic test
capable of serving as a widespread screening tool to prevent EAC deaths through early detection of esophageal precancer and cancer in
patients with 3 or more risk factors.
Clinical
Guidelines for At-Risk Population
The
subgroup of long-standing or severe GERD patients at-risk for BE and progression to EAC is well defined in clinical practice guidelines,
including the American College of Gastroenterology (ACG) BE Guidelines. In its Recommendation 5, the ACG suggests a single screening
endoscopy in patients with chronic GERD symptoms and 3 or more additional risk factors for BE, including male sex, age greater than 50
years, White race, tobacco smoking, obesity, and family history of BE or EAC in a first-degree relative.
An
ACG clinical guideline entitled “Diagnosis and Management of Barrett’s Esophagus: An Updated ACG Guideline,”
the first such update since 2016, was published online last year in the American Journal of Gastroenterology. The clinical guideline
reiterates the ACG’s long-standing recommendation for esophageal precancer screening in at-risk patients with GERD. For the first
time, however, the clinical guideline also endorses nonendoscopic biomarker screening as an acceptable alternative to costly and invasive
endoscopy stating that “a swallowable nonendoscopic capsule device combined with a biomarker is an acceptable alternative to endoscopy
for BE.” The clinical guideline specifically mentions EsoCheck, along with Lucid’s EsophaCap® device, as such swallowable,
nonendoscopic esophageal cell collection devices, as well as methylated DNA biomarkers such as EsoGuard. The summary of evidence for
this recommendation includes a reference to the seminal NIH-funded, multicenter, case-control study published in 2018 in Science Translational
Medicine, which demonstrated that EsoGuard is highly accurate at detecting esophageal precancer and cancer, including on samples
collected with EsoCheck.
In
July 2022, the AGA published in their “Clinical Practice Update on New Technology and Innovation for Surveillance and Screening
in Barrett’s Esophagus” updated clinical guidance that mirrors the same furnished by the ACG as described above, endorsing
the use of non-endoscopic cell collection tools to screen for BE like our EsoCheck Cell Collection Device, which is cited in the update,
as an acceptable alternative to endoscopy to directly address the need for noninvasive screening tools that are easy to administer, patient
friendly, and cost-effective for the detection of BE. The clinical practice update by the AGA also significantly expands the target population
for esophageal precancer screening, including for EsoGuard and EsoCheck, by recommending, for the first time, screening in at-risk patients
without symptoms of GERD. The AGA does so by adding a history of chronic GERD as merely an additional, seventh risk factor to the six
risk factors for BE and EAC that have traditionally identified at-risk symptomatic patients recommended for screening.
Commercialization
Our
EsoGuard commercialization efforts span multiple channels including targeting primary care physicians and GI physicians, who have generally
embraced our message that EsoGuard has the potential to expand the funnel of BE-EAC patients who will need long term EGD surveillance
and, potentially, treatment with endoscopic esophageal ablation.
To
assure sufficient testing capacity and geographic coverage, we have built our own network of Lucid Test Centers, staffed by Lucid-employed
clinical personnel, where patients can undergo the EsoCheck procedure and have the sample sent for EsoGuard testing at Lucid’s
CLIA-certified laboratory. Our current test center network currently includes locations in metropolitan areas in Arizona, California,
Colorado, Florida, Idaho, Illinois, Nevada, Ohio, Oregon, Texas and Utah.
In
addition to our base test center network, Lucid has established a satellite test center program, whereby we are expanding our footprint
by making our personnel available to perform cell collection services in physician offices. Further, we have sought to expand our outreach
by successfully conducting multiple “#CheckYourFoodTube Precancer Testing Event” for organizations such as the San Antonio
Fire Department, where samples are collected from the organization’s employees for testing with EsoGuard at Lucid’s CLIA-certified
laboratory.
We
have also established an EsoGuard Telemedicine Program, in partnership with UpScript, LLC, an independent third-party telemedicine provider,
that accommodates EsoGuard self-referrals from direct-to-consumer marketing.
Reimbursement
and Market Access
As
noted above, in December 2019, we secured “gapfill” determination for EsoGuard’s PLA code 0114U through the CMS CLFS
process. This allowed us to engage directly with Medicare contractor Palmetto GBA and its MolDx Program on CMS payment and coverage.
In October 2020, CMS granted EsoGuard final Medicare payment determination of $1,938.01, effective January 1, 2021.
A
proposed Local Coverage Determination (“LCD”) DL39256, entitled “Molecular Testing for Detection of Upper Gastrointestinal
Metaplasia, Dysplasia, and Neoplasia” was published recently on the Center for Medicare and Medicaid Services (“CMS”)
website by MAC Palmetto GBA. The proposed LCD is a further step in Lucid’s efforts to secure Medicare coverage and payment for
EsoGuard. The proposed LCD, which the CMS website explicitly characterizes as a “work in progress” for “public review,”
outlines criteria that MolDX expects upper gastrointestinal precancer and cancer molecular diagnostic tests to meet. These criteria include
active GERD with at least two risk factors, as well as evidence of analytic validity, clinical validity, and clinical utility. Although
the proposed LCD indicated that it found that no currently existing test has fulfilled all criteria, it indicated that it will “monitor
the evidence and will provide coverage based on the pertinent literature and society recommendations.” Notably, the proposed LCD
pre-dated, and therefore does not include consideration of, the most recent AGA clinical practice update endorsing swallowable, nonendoscopic
capsule devices combined with a biomarker, such as EsoCheck and EsoGuard, as an alternative to endoscopy. The publication of the proposed
LCD triggers a written comment period, and MolDX also held an open meeting on May 10, 2022, during which stakeholders and other interested
parties will have the opportunity to address the proposed LCD. We presented at the public meeting and made a written submission during
the comment period as well. A final LCD will not be issued until the MAC has had the opportunity to assess and consider all stakeholder
comments.
While
we await a Palmetto MolDX LCD coverage determination, Lucid is aggressively pursuing EsoGuard commercial insurer payment and coverage.
Although the claim adjudication cycle can be prolonged during the early commercialization of a new test, Lucid has received out-of-network
commercial insurance payments for the EsoGuard test, and has entered into agreements with insurers that provide access to, in the aggregate,
over 70 million patients.
Clinical
Utility and Clinical Trials
Demonstrating
EsoGuard’s clinical utility, which requires providing evidence that the test has a meaningful impact on clinical practice, is very
important for a variety of purposes, including, importantly, for Medicare and private payor payment and coverage. It has been established
that one of the most important factors to private payors in deciding whether to grant payment and coverage will be demonstration that
the EsoGuard test, when ordered by physicians, provides information that can be used to
identify or exclude patients who would benefit from additional management and/or treatment. Clinical utility studies are also important
for general EsoGuard commercialization by facilitating physician understanding of test indications and potential benefit to the patients.
We
are currently seeking to accelerate our collection of clinical utility data through a range of trials that can be efficiently executed.
These efforts include a planned investigator-initiated, retrospective analysis of prospectively collected data on the approximately 400
San Antonio fire fighters who underwent testing as part of a community-sponsored cancer awareness event (in
respect of which we expect to publish results in the first half of 2023); an ongoing investigator-initiated, retrospective, single-center,
study with 500 patients (in respect of which we expect to publish results mid-2023), a virtual-patient randomized controlled trial with
intended recruitment of 100-200 physician participants (in respect of which we expect to publish
results this year); a Lucid-sponsored multi-center, prospective, observational study with 500 patients; and a Lucid-sponsored
registry at existing Lucid Test Centers, whereby all patients undergoing EsoCheck testing will be given the opportunity to provide informed
consent and contribute data about their risk factors, EsoGuard results, and subsequent diagnostic and/or therapeutic journey. Both Lucid-sponsored
observational/registry studies expect to have preliminary results and/or interim analysis before the end of 2023.
As
previously disclosed, consequently, we have decided to delay for the time being the two previously commenced clinical trials, the “EsoGuard
screening study” (“BE-1”) and the “EsoGuard case-control study” (“BE-2”), as we are devoting
our clinical resources to the studies cited above, which we expect will more efficiently generate the clinical data we are currently
prioritizing to drive EsoGuard commercialization.
Manufacturing
EsoCheck
is currently manufactured for us by our partners Coastline International, a high-volume device manufacturer, and Sage Product
Development. Through mid-2023, we expect to further transition from Sage to Coastline as the manufacturing process is further
optimized. Our current line capacity can produce up to 25,000 units per year. With Coastline’s improvement and expansion,
there is capacity to scale exponentially. Our EsoGuard Specimen Kits are currently manufactured for us by our partner Path-Tec. The
warehousing, logistics, fulfillment and customer support of our products is managed for us by our partners HealthLink International
(a leading third-party logistics company) and Path-Tec.
License
Agreement
Under
the terms of Lucid’s license agreement with Case Western Reserve University (“CWRU”), Lucid acquired an exclusive worldwide
right to use the intellectual property rights to the EsoGuard and EsoCheck technology for the detection of changes in the esophagus and
on sample preservation. Lucid is required to pay CWRU royalties on net sales of licensed products as follows: 5% of net sales of less
than $100 million per year; and 8% of net sales greater than $100 million per year. Lucid is also required to pay CWRU minimum annual
royalty payments as follows: $50,000 per year, beginning January 1 following the first anniversary of a commercial sale of a licensed
product; $150,000 per year, if net sales of a licensed product exceed $25 million in a year; $300,000 per year, if net sales of a licensed
product exceed $50 million in a year; and $600,000 per year, if net sales of a licensed product exceed $100 million in a year. Minimum
yearly royalty amounts are subject to increase based on the percentage change in the CPI-W Consumer Price Index and are credited against
the royalties otherwise due. The license agreement was subject to four regulatory and commercialization milestones, of which one remains
unachieved and unpaid. The remaining milestone is the FDA PMA submission of a licensed product, upon the achievement of which we will
pay CWRU a milestone payment of $200,000. The license agreement terminates upon the expiration of the last-to-expire licensed patent,
or on May 12, 2038, in countries where no such patents exist, or upon expiration of any exclusive marketing rights for a licensed product
that have been granted by FDA or other U.S. government agency, whichever comes later. The EsoCheck patents, which are currently the last
to expire, begin to expire in May 2035.
Regulatory
In
June 2019, we received FDA 510(k) clearance to market EsoCheck in the U.S. as a device indicated for use in the collection and retrieval
of surface cells of the esophagus in adults followed by FDA 510(k) clearance in 2022, expanding the use of EsoCheck in adults and pediatric
populations in the U.S. In December 2019, our CLIA-certified then-laboratory partner, completed documentation of EsoGuard analytical
validity allowing us to commercialize it as a Laboratory Developed Test (LDT).
In
February 2020, we received FDA “Breakthrough Device Designation” for EsoGuard as an in-vitro diagnostic (“IVD”)
medical device. The FDA Breakthrough Device Program was created to offer patients more timely access to breakthrough technologies which
provide for more effective treatment or diagnosis of life-threatening or irreversibly debilitating human disease or conditions by expediting
their development, assessment and review through enhanced communications and more efficient and flexible clinical study design, including
more favorable pre/post market data collection balance. The Centers for Medicare and Medicaid Services and the United States Congress
continue to work to provide an expedited coverage pathway for emerging technologies.
In
May 2021, we received CE Mark certification for EsoCheck (under the Medical Devices Directive 93/42/EEC), and in June 2021, we completed
CE Mark self-certification for EsoGuard (under the European In-Vitro Diagnostic Devices Directive (IVDD 98/79/EC)), indicating both may
be marketed in CE Mark European countries.
Our
longer-term strategy is to secure a specific indication, based on published guidelines, for BE screening in certain at-risk populations
using EsoGuard on samples collected with EsoCheck. This use of EsoGuard together with EsoCheck as a screening system must be cleared
or approved by the FDA as an IVD device.
Laboratory
Operations
On
February 25, 2022, our new, wholly owned subsidiary, LucidDx Labs Inc. (“LucidDx Labs”), acquired from RDx, certain licenses
and other related assets necessary for LucidDx Labs to operate its own new CLIA-certified, CAP-accredited clinical laboratory located
in Lake Forest, CA. Since March 2022, we have conducted EsoGuard testing at our own laboratory with, until recently, the assistance of
RDx, which had continued to provide certain testing and related services for the laboratory in accordance with the terms of a management
services agreement (“MSA-RDx”), dated and effective February 25, 2022. Recently, however, the Company accelerated the development
of internal resources necessary to operate the laboratory entirely on its own. Accordingly, Lucid’s subsidiary LucidDx Labs and
RDx agreed terminate the MSA-RDx effective as of February 10, 2023, such that LucidDx Labs now operates the laboratory itself, which
the Company believes will improve the efficiency of the performance of the EsoGuard assay.
Competition
The
U.S. market for esophageal cancer (i.e., EAC) and pre-cancer (i.e., BE, with or without dysplasia) screening is large, consisting of
more than 30 million at-risk individuals over the age of 50. Given the large market for pre-cancer screening, we likely will face numerous
competitors, some of which possess significantly greater financial and other resources and development capabilities than us. Our EsoGuard
test faces competition from procedure-based detection technologies such as upper endoscopy, and other screening technologies such as
multi-cancer early detection products. Our EsoCheck device faces competition from other manufactures with devices designed to collect
cell samples from targeted regions of the esophagus. For example, Cytosponge is a small mesh sponge within a soluble gelatin capsule
that dissolves in the stomach and then is pulled thru the targeted region brushing the lining of the esophagus and then later retrieved,
although, unlike EsoCheck, it is unprotected from contamination. Our competitors may also be developing additional methods of detecting
esophageal cancer and pre-cancer that have not yet been announced.
Accordingly,
the market for our products is highly competitive and is characterized by extensive research and clinical efforts and rapid technological
change. In order to compete effectively, EsoGuard and EsoCheck will have to achieve market acceptance, receive adequate insurance coverage
and reimbursement, be cost effective and be simultaneously safe and effective. We believe that the principal competitive factors in our
markets are:
● diagnostic accuracy and the quality of outcomes for medical conditions;
● acceptance by physicians and the medical device market generally;
● ease of use and reliability;
● technical leadership and superiority;
● effective marketing and distribution;
● speed to market; and
● product price and qualification for coverage and reimbursement.
Most
of our existing and potential competitors have substantially greater financial, marketing, sales, distribution, manufacturing and technological
resources. We may be unable to compete effectively against our competitors either because their products and services are superior or
more cost efficient, or because of they have access to greater resources than us. These competitors may have greater name recognition
than we do. Many of these competitors have obtained all desirable FDA or other regulatory approvals, and superior patent protection,
for their products. Certain of our competitors have already commercialized their products, and others may commercialize their products
in advance of our products. In addition, our competitors may make technical advances that render our products obsolete. We may be unable
to respond to such technical advances.
Veris
Cancer Care Platform
Overview
In
May 2021, we formed Veris Health, a majority-owned subsidiary, focused on digital health technology. In connection with its formation,
Veris Health acquired Oncodisc, a digital health company with groundbreaking tools to improve personalized cancer care through remote
patient monitoring. Oncodisc’s core technologies include the first intelligent implantable vascular access port with biologic sensors
and wireless communication, combined with an oncologist-designed remote digital healthcare platform that provides patients and physicians
with new tools to improve outcomes and optimize the delivery of cost-effective care through remote monitoring and data analytics.
Oncodisc
was founded in 2018 experienced physician entrepreneurs, James Mitchell, M.D., who joined Veris Health as its full-time Chief Medical
Officer, and Andrew Thoreson, M.D., who serves as a Veris Health consultant. They previously co-founded Redsmith, Inc., an interventional
catheter company whose technology was acquired by C.R. Bard Inc., now BD Inc. (NYSE: BDX). Oncodisc received a National Science Foundation
(“NSF”) Small Business Innovation Research (“SBIR”) grant award to support its early work and completed both
the MedTech Innovator Accelerator and UCSF Rosenman Institute Accelerator programs.
The
Veris Cancer Care Platform (“CCP”) is a digital cancer care platform with physiologic data collection, symptom reporting
and telehealth functions, designed to improve personalized cancer care through remote patient monitoring. Cancer patients enrolled in
the Veris CCP receive a VerisBoxTM with Veris-branded Bluetooth enabled connected health care devices. The devices transmit clinical
data to cancer care teams to detect early signs of common cancer-related complications, provide longitudinal trends of physiologic and
clinical data, and offer data-driven risk management tools for precision oncology. Veris CCP integrates directly with practices’
and systems’ Electronic Health Record (“EHR”) systems, allowing care teams to easily view and interact with this data.
We are also currently developing a groundbreaking implantable physiologic monitor containing biologic sensors capable of generating continuous
data on key physiologic parameters known to predict adverse outcomes in cancer patients undergoing treatment. The implantable will seamlessly
interact with the Veris CCP. These technologies are the subject of multiple patent applications and one issued patent.
Veris
Health leverages a business-to-business sales model. Its software-as-a-service recurring-revenue business model seeks to generate 100%
recurring revenue through oncology practice and hospital-based subscriptions. These entities pay monthly fees for each patient on the
platform, through which they are able to drive revenues from remote physiologic monitoring (and, in the future, device implantation)
under existing CPT codes, as well as through the upcoming CMS Enhancing Oncology Model (EOM) bonuses and incentives. Veris also plans
to build a commercialization model around the oncology data it is collecting. We have identified multiple potential use cases across
a number of verticals, including clinical trials, commercial use cases, and as a means to improve patient care.
In
addition to targeting the oncology market, Veris plans to expand into the hospital-at-home market, cardiovascular diseases, end-stage
renal disease, and lung disorders like COPD. We have already initiated R&D efforts around an enhanced implantable cardiac monitor
capable of detecting cardiac arrhythmias and other physiologic parameters critical for high-risk cardiac patients. Future devices will
combine novel sensing technology with seamless communication, engaging user interface design, and data analytics driving actionable clinical
insights for patients with congestive heart failure. These technologies will then be expanded for high-risk kidney disease and pulmonary
patients.
Market
Opportunity
In
2022, approximately 1.9 million people in the U.S. were newly diagnosed with cancer, and cancer incidence in the U.S. is expected to
continue to increase. Cancer patients face high rates of complications during the courses of their treatment which drive poor patient
outcomes and healthcare costs. One driver of these issues is avoidable hospitalizations. We believe Veris Health’s offerings can
help drive costs down and improve outcomes through providing care teams with better, more continuous data.
Based
on the aforementioned cancer prevalence in the U.S. and our current business model, we believe Veris Health’s total addressable
U.S. market opportunity exceeds $2 billion. In the future, we believe this opportunity will only expand through the implantable physiologic
monitor, data commercialization, and the expansion into other markets aside from oncology.
Commercialization/Sales
Our
Veris commercialization efforts have targeted the full spectrum of oncology care providers, with a focus on independent oncology practices,
participants in CMS’s Oncology Care Model (OCM) and EOM, and innovative, progressive health systems. The growing adoption of value-based
models has provided a strong tailwind, as the Veris CCP addresses many requirements of these programs, including electronic Patient Reported
Outcomes (“ePROs”) and the use of data for quality improvement.
Manufacturing
The
components comprising the Veris Cancer Care Platform are currently supplied to us by our partners TransTek and their U.S.-based subsidiary,
Mio Labs. Each has passed a SOC-2 audit by an outside auditor. The final packaging of the overall box and order fulfillment is managed
by Impilo, a partner with TransTek and Mio Labs. The customer support is currently managed internally, while partnering with Zendesk
for customer service management.
Regulatory
The
Veris CCP software is considered a non-device Medical Device Data System (“MDDS”) that is excluded from the statutory definition
of a medical device under the FDC Act and as confirmed in the FDA’s MDDS Guidance: Medical Device Data Systems, Medical Image Storage
Devices, and Medical Image Communications Devices. Therefore, Veris CCP is not subject to the FDA’s regulatory requirements for
devices.
Veris
Health is also developing an implantable cardiac monitor and is currently interacting with the FDA via pre-submission process, seeking
agreement on regulatory strategy and required testing to seek clearance of the monitor. We current plan to make our 510(k) submission
for the implantable monitor in late 2023.
As
Veris Health is currently sourcing the devices included in the VerisBoxTM from the third-party 510(k) holders for those products,
such holders are responsible for any losses, damages, claims or other liabilities that may arise with respect to those devices used with
the Veris CCP software, notwithstanding Veris Health commercial branding being added to the devices or the devices’ packaging.
Competition
The
U.S. market for cancer patient care is large. There are many existing competitors in the remote patient monitoring space, some of which
possess significantly greater financial and other resources and development capabilities than us. Our Veris CCP faces competition from
other digital care platforms providing many of the same features, including EHR integration and remote patient monitoring capabilities.
While we are not aware of other implantable physiologic monitors containing biologic sensors, our competitors may also be developing
similar devices that have not yet been announced.
Product
Pipeline
Below
is a summary of certain of the other leading products within our development pipeline. While we currently are devoting substantially
all of our resources to the acceleration of EsoGuard and Veris Cancer Care Platform commercialization, as resources permit, we will continue
to explore innovative technologies, such as our EsoCure, CarpX and NextFlo products as more fully described below, that fulfill our project
selection criteria without limiting ourselves to any target specialty or condition.
Esocure
In
connection with our efforts to expand our presence in the EAC diagnostic market, we are also developing the EsoCure Esophageal Ablation
Device, with the intent to allow a clinician to treat dysplastic BE before it can progress to EAC, a highly lethal esophageal cancer,
and to do so without the need for complex and expensive capital equipment. We have successfully completed a pre-clinical feasibility
animal study of EsoCure demonstrating excellent, controlled circumferential ablation of the esophageal mucosal lining. An acute and survival
animal study of EsoCure Esophageal Ablation Device has also been completed, demonstrating successful direct thermal balloon catheter
ablation of esophageal lining through the working channel of a standard endoscope. When resources permit, we plan to conduct additional
development work and animal testing of EsoCure to support a future FDA 510(k) submission.
CarpX
CarpX
is a patented, single-use, disposable, minimally invasive surgical device for use in the treatment of carpal tunnel syndrome. We believe
CarpX is designed to allow the physician to relieve the compression on the median nerve without an open incision or the need for endoscopic
or other imaging equipment, and therefore will be significantly less invasive than existing treatments. To use CarpX, the operator first
advances a guidewire through the carpal tunnel under the ligament, and then advanced over the wire and positioned in the carpal tunnel
under ultrasonic and/or fluoroscopic guidance. When the CarpX balloon is inflated it creates tension in the ligament positioning the
cutting electrodes underneath it and creates space within the tunnel, providing anatomic separation between the target ligament and critical
structures such as the median nerve. Radiofrequency energy is briefly delivered to the electrodes, rapidly cutting the ligament, and
relieving the pressure on the nerve. We believe CarpX will be significantly less invasive than existing treatments.
CarpX
received FDA 510(k) marketing clearance in April 2020, with the first commercial procedure successfully performed in December 2020. In
May 2021 European CE Mark Certification was received for CarpX. Our limited-release commercialization efforts through 2022 were focused
on engaging key opinion hand surgeons designed to solicit input for ergonomic improvements to the device, procedure development and surgical-time
optimization, and ease of use. As a result of this clinical input, we have initiated a product development project to incorporate intraluminal
ultrasound into the device to include real time imaging of the ligament to be cut together with critical anatomic structures, and will
continue to pursue that project, as resources permit.
PortIO
Our
PortIO implantable intraosseous vascular access device is being developed as a means for infusing fluids, medications and other substances
directly into the bone marrow cavity and from there into the central venous circulation. The intraosseous route provides a means for
infusing fluids, medications and other substances directly into the bone marrow cavity which communicates with the central venous circulation
via nutrient and emissary veins. This route is well established, having been used for decades in a variety of settings including trauma,
especially military trauma, and pediatric emergencies. It has been shown to be bioequivalent to the intravenous route. Complication rates
are low and there are few contraindications. Currently available intraosseous devices pass through the skin into the bone and are therefore
limited to short term use. PortIO is a novel, implantable intraosseous vascular access device which does not require accessing the central
venous system and does not have an indwelling intravascular component. It is designed to be highly resistant to occlusion and, we believe,
may not require regular flushing. It features simplified, near-percutaneous insertion and removal, without the need for surgical dissection
or radiographic confirmation.
Recent
Developments
Business
Status
of Lucid Clinical Trials
Lucid
is currently seeking to accelerate our collection of clinical utility data through a range of trials that can be efficiently executed.
These efforts include a planned investigator-initiated, retrospective analysis of prospectively collected data on the approximately 400
San Antonio fire fighters who underwent testing as part of a community-sponsored cancer awareness event (in
respect of which we expect to publish results in the first half of 2023); an ongoing investigator-initiated, retrospective, single-center,
study with 500 patients (in respect of which we expect to publish results mid-2023), a virtual-patient randomized controlled trial with
intended recruitment of 100-200 physician participants (in respect of which we expect to publish
results this year); a Lucid-sponsored multi-center, prospective, observational study with 500 patients; and a Lucid-sponsored
registry at existing Lucid Test Centers, whereby all patients undergoing EsoCheck testing will be given the opportunity to provide informed
consent and contribute data about their risk factors, EsoGuard results, and subsequent diagnostic and/or therapeutic journey. Both Lucid-sponsored
observational/registry studies expect to have preliminary results and/or interim analysis before the end of 2023.
As
previously disclosed, consequently, Lucid has decided to delay for the time being the two previously commenced clinical trials, the “EsoGuard
screening study” (“BE-1”) and the “EsoGuard case-control study” (“BE-2”), as Lucid is devoting
our clinical resources to the studies cited above, which we expect will more efficiently generate the clinical data Lucid is currently
prioritizing to drive EsoGuard commercialization.
LucidDx
Labs Laboratory Operations Update
On
February 14, 2023, Lucid Diagnostics and LucidDx Labs Inc. entered into an agreement (the “MSA Termination Agreement”)
with RDx, pursuant to which the parties mutually agreed to terminate the MSA-RDx without cause. The termination was effective as February
10, 2023. Until the termination of the MSA-RDx, RDx had continued to provide certain testing and related services for the Laboratory
in accordance with the terms of the MSA-RDx. Recently, however, Lucid accelerated the development of internal resources necessary to
operate the Laboratory entirely on its own. Accordingly, the Company believes that termination of the MSA-RDx will improve the efficiency
of the performance of the EsoGuard assay.
Among
other things, the MSA Termination Agreement reduces the remaining amounts of the earnout payments and management fees due under the APA-RDx
and the MSA-RDx to $725,000 (from the $3,450,000 that would otherwise have been payable under the APA and MSA if the MSA had remained
in effect through the balance of its stated term), resulting in a net savings to Lucid Diagnostics of $2,725,000. The payment was satisfied
through the issuance of 553,436 shares of Lucid Diagnostics’ common stock on February 25, 2023. Lucid Diagnostics was not required
to make any cash payments in connection with the termination.
#CheckYourFoodTube
Events
In
January 2023, Lucid successfully completed its first #CheckYourFoodTube Precancer Testing Event, in partnership with Rachelle Hamblin,
M.D., M.P.H., and the San Antonio Fire Department (SAFD), to detect esophageal precancer in at-risk members of the department. The SAFD
testing event was held over two weekends in January, which has been designated as Firefighter Cancer Awareness Month by the International
Association of Fire Fighters (IAFF). A total of 391 members, nearly one-quarter of the department, who were deemed by Dr. Hamblin to
be at-risk for esophageal precancer, underwent a brief, on-site, noninvasive cell collection procedure, performed by Lucid clinical personnel
using its EsoCheck® Esophageal Cell Collection Device. Firefighters with suspected esophageal precancer based on a positive
EsoGuard result were identified, including some less than forty years of age, and will undergo appropriate monitoring and treatment,
as indicated by clinical practice guidelines, to prevent progression to esophageal cancer. These events, which Lucid looks to expand
across the country, are an extension of Lucid’s recently introduced and expanding satellite Lucid Test Center (sLTC) program, which
brings our precancer testing directly to patients—at their physician’s office and now at large testing day events. Lucid
demonstrated that its nurse practitioners can each perform up to fifty EsoCheck procedures in a day, and its laboratory team handled
over two hundred incoming samples in a day, while maintaining turnaround times at target. These successes provide an excellent foundation
for future testing events as we continue to drive EsoGuard commercialization using all the tools at our disposal.
Veris
Health Commercialization Update
In
December 2022, Veris Health signed a license agreement for the Veris CCP software with its first customer, New Jersey Cancer Care. Since,
Veris Health onboarded the first cohort of patients of that practice onto the Veris CCP as well, and has signed license agreements with
two additional cancer centers. These successes lay the groundwork for Veris Health’s expansion plans with respect to the Veris
CCP software as it seeks to onboard cancer centers and patients across the country.
NASDAQ
Notice
On
December 29, 2022, the Company received a notice from the Listing Qualifications Department of Nasdaq stating that, for the prior 30
consecutive business days (through December 28, 2022), the closing bid price of the Company’s common stock had been below the minimum
of $1 per share required for continued listing on the Nasdaq Capital Market under Nasdaq Listing Rule 5550(a)(2). The notification letter
stated that the Company would be afforded 180 calendar days (until June 27, 2023) to regain compliance. In order to regain compliance,
the closing bid price of the Company’s common stock must be at least $1 for a minimum of ten consecutive business days. In February
2023, the Company distributed a proxy statement for a special meeting of shareholders to be held on March 31, 2023 (the “Special
Meeting”), at which the Company will be seeking approval of an amendment to the Company’s Certificate of Incorporation, to
effect, at any time prior to the one-year anniversary date of the Special Meeting, (i) a reverse split of the Company’s outstanding
shares of common stock at a specific ratio, ranging from 1-for-5 to 1-for-15, to be determined by the board of directors of the Company
in its sole discretion, and (ii) an associated reduction in the number of shares of common stock the Company is authorized to issue,
from 250,000,000 shares to 50,000,000 shares. If the proposed reverse stock split is approved, the Company anticipates it will regain
compliance with the Nasdaq requirements for continued listing.
Payroll and Benefit Expense Reimbursement Agreement
On
November 30, 2022, PAVmed and Lucid entered into a payroll and benefit expense reimbursement agreement (the “PBERA”). Historically,
PAVmed has paid for certain payroll and benefit-related expenses in respect of Lucid’’s personnel on behalf of Lucid, and
Lucid has reimbursed PAVmed for the same. Pursuant to the PBERA, PAVmed will continue to pay such expenses, and Lucid will continue to
reimburse PAVmed for the same. The PBERA now provides that the expenses will be reimbursed on a quarterly basis or at such other frequency
as the parties may determine, in cash or, subject to approval by the board of directors of each of PAVmed and Lucid, in shares of Lucid’s
common stock, with such shares valued at the volume weighted average price of such stock during the final ten trading days preceding
the later of the two dates on which such stock issuance is approved by the board of directors of each of PAVmed and Lucid (subject to
a floor price of $0.40 per share), or in a combination of cash and shares. However, in no event shall Lucid issue any shares of its common
stock to PAVmed in satisfaction of all or any portion of the expenses if the issuance of such shares of its common stock would exceed
the maximum number of shares of common stock that the Issuer may issue under the rules or regulations of The Nasdaq Stock Market LLC
(“Nasdaq”), unless Lucid obtains the approval of its stockholders as required by the applicable rules of the Nasdaq for issuances
of shares of its common stock in excess of such amount.
Financing
Securities
Purchase Agreement - March 31, 2022 - Senior Secured Convertible Note - April 4, 2022 and Senior Secured Convertible Note - September
8, 2022
Effective
as of March 31, 2022, we entered into a Securities Purchase Agreement (“SPA”) with an accredited institutional investor (“Investor”,
“Lender”, and /or “Holder”), pursuant to which we agreed to sell, and the Investor agreed to purchase an aggregate
of $50.0 million face value principal of Senior Secured Convertible Notes. The SPA provided for the sale to the Investor of an initial
Senior Secured Convertible Note with a face value principal of $27.5 million, which closed on April 4, 2022 (the “April 2022 Senior
Convertible Note”). The SPA also provided for sales of additional Senior Secured Convertible Notes in one or more additional closings
(upon the satisfaction of certain conditions), with an aggregate face value principal of up to an additional $22.5 million. The April
2022 Senior Convertible Note proceeds were $24.4 million after deducting a $2.5 million lender fee and the Company’s offering costs
of approximately $0.6 million, inclusive primarily of $0.5 million placement agent fees.
On
September 8, 2022, we completed an additional closing under the SPA, in which we sold to the Investor an additional Senior Secured Convertible
Note with a face value principal of $11.25 million (the “September 2022 Senior Convertible Note”). The September 2022 Senior
Convertible Note proceeds were $10.0 million after deducting a $1.0 million lender fee and the Company’s offering costs of approximately
$0.2 million, inclusive primarily of placement agent fees.
See
our accompanying consolidated financial statements Note 14, Debt, for further discussion of the SPA dated March 31, 2022 and the
senior convertible notes.
Lucid
Diagnostics Inc. - Committed Equity Facility and ATM Facility
In
March 2022, our majority-owned subsidiary, Lucid Diagnostics, entered into a committed equity facility with an affiliate of Cantor Fitzgerald
(“Cantor”). Under the terms of the facility, Cantor committed to purchase up to $50 million of Lucid Diagnostics common stock
from time to time upon the request of Lucid Diagnostics. While there are distinct differences, the facility is structured similarly to
a traditional at-the-market equity facility, insofar as it allows Lucid Diagnostics to raise primary capital on a periodic basis at prices
based on the existing market price. Through December 31, 2022, 680,263 shares of common stock of Lucid Diagnostics were issued under
this facility for total proceeds of approximately $1.8 million.
In
November 2022, Lucid Diagnostics also entered into an “at-the-market offering” for up to $6.5 million of its common stock
that may be offered and sold under a Controlled Equity Offering Agreement between Lucid Diagnostics and Cantor Fitzgerald & Co. In
the year ended December 31, 2022, there were no Lucid Diagnostics shares sold through their at-the-market equity facility. Subsequent
to December 31, 2022, through March 9, 2023, Lucid Diagnostics sold 230,068 shares through its at-the-market equity facility for approximately
$0.3 million.
Lucid
Diagnostics - Series A Preferred Stock Offering
On
March 7, 2023, Lucid entered into subscription agreements for the sale of 13,625 shares (the “LucidSeries A
Preferred Stock”). Each share of the Lucid Series A Preferred Stock has a stated value of $1,000 and a conversion price of
$1.394. The terms of the Lucid Series A Preferred Stock also include a one times preference on liquidation and a right to receive
dividends equal to 20% of the number of shares of Lucid common stock into which such Lucid Series A Preferred Stock is convertible,
payable on the one-year and two-year anniversary of the issuance date. The Lucid Series A Preferred Stock is a non-voting security,
other than with respect to limited matters related to changes in terms of the Lucid Series A Preferred Stock. The aggregate gross
proceeds from the sale of shares in such offering were $13.625
million.
Lucid
Diagnostics - Private Placement - Securities Purchase Agreement
Effective
as of March 13, 2023, Lucid entered into a Securities Purchase Agreement (“Lucid SPA”) with an accredited
institutional investor (“Lucid Investor”, “Lucid Lender”, and /or “Lucid Holder”), pursuant to
which Lucid agreed to sell, and the Lucid Investor agreed to purchase a Senior Secured Convertible Note with a face value principal
of up to $11.1 million (the “March 2023 Lucid Senior Convertible Note”). The issuance of the March 2023 Lucid Senior
Convertible Note is subject to customary closing conditions.
The
March 2023 Lucid Senior Secured Convertible Note would have a 7.875% annual stated interest rate, a contractual conversion price of $5.00
per share of Lucid’s common stock (subject to standard adjustments in the event of any stock split, stock dividend, stock combination,
recapitalization or other similar transaction), and a contractual maturity date of the two-year anniversary of the date of issuance.
The March 2023 Lucid Senior Convertible Note would be convertible into or otherwise paid in shares of Lucid’s common stock.
Under