Item 1A Risk Factors 16
Item 1B. Unresolved Staff Comments 34
Item 1C. Cybersecurity 35
Item 2. Property 35
Item 3. Legal Proceedings 35
Item 4. Mine Safety Disclosures 35
PART II
Item 6. [Reserved] 36
Item 7A. Quantitative and Qualitative Disclosure About Market Risk 47
Item 8. Financial Statements and Supplementary Data 48
Item 9A. Controls and Procedures 48
Item 9B. Other Information 48
Item 9C. Disclosure Regarding Foreign Jurisdictions that Prevent Inspections 48
PART III
Item 10. Directors, Executive Officers, and Corporate Governance 49
Item 11. Executive Compensation 49
Item 14. Principal Accountant Fees and Services 49
PART IV
Item 15. Exhibits and Financial Statement Schedules 50
i
FORWARD-LOOKING
STATEMENTS
This
Annual Report on Form 10-K (this “Form 10-K”), including the discussion and analysis of our consolidated
financial condition and results of operations set forth under Item 7 of this Form 10-K, 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 those expressed or implied 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 the Form 10-K under the heading “Risk
Factors.”
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;
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 results, plans, and/or objectives disclosed in our forward-looking statements, and the intended or expected developments and/or other events disclosed in our forward-looking statements may not actually
occur, and accordingly 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 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 structured to be a multi-product life sciences company organized to advance a pipeline of innovative healthcare technologies. Led
by a team of highly skilled personnel with a track record of bringing innovative products to market, PAVmed is focused on innovating,
developing, acquiring, and commercializing novel products that target unmet needs with large addressable market opportunities. Leveraging
our corporate structure—a parent company that will establish distinct subsidiaries for each financed asset—we have the flexibility
to raise capital at the PAVmed level to fund product development, or to structure financing directly into each subsidiary in a manner
tailored to the applicable product, the latter of which is our current strategy given prevailing market conditions.
Our
current focus is multi-fold. We continue to pursue commercial expansion and execution of EsoGuard, which is the flagship product of
our majority-owned subsidiary Lucid Diagnostics Inc. (Nasdaq: LUCD) (“Lucid” or “Lucid Diagnostics”). In
addition, through a separate majority-owned subsidiary, Veris Health Inc. (“Veris” or “Veris Health”), we are focused on entering into
strategic partnership opportunities with leading academic oncology systems to expand access to the Veris Platform. In terms of other
existing products and technologies, we have created an incubator-type platform where we are looking to obtain financing on a
product-by-product basis as necessary to advance each asset to a meaningful inflection point along its path to commercialization.
Finally, as resources permit, we will continue to explore external innovations that fulfill our project selection criteria without
limiting ourselves to any target sector, specialty or condition.
EsoGuard
and EsoCheck
We
believe that the flagship product of our majority-owned subsidiary 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 testing tool with the goal of preventing 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 accurate, non-invasive, patient-friendly testing for the early detection of EAC and Barrett’s
Esophagus (“BE”), including dysplastic BE and related pre-cursors to EAC in patients with chronic 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”, in July 2022, the American Gastroenterology
Association (“AGA”) 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 approximates $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. As discussed below under the heading “Reimbursement and Market Access”,
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). Until recently,
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 testing tool with the goal of preventing 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 in April 2022 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 American Gastroenterology Association (“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 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 undertaken multiple ways for patients have access to our test. Initially,
we built a limited network of our own physical 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 own test center locations, we have broadened patient access to our test by establishing a satellite test center program,
whereby we are making our personnel available to perform cell collection services inside physician offices or in certain geographies,
closely nearby physician offices (in Florida, for the time being) by way of our Lucid Mobile Testing Unit.
Also,
in January 2023, we completed our first #CheckYourFoodTube Precancer Testing Event, with the San Antonio Fire Department (the
“SAFD”) during Firefighter Cancer Awareness Month as designated by the International Association of Fire Fighters
(IAFF). A total of 391 members who were deemed to be at-risk for esophageal precancer, underwent a brief, on-site, noninvasive cell
collection procedure, performed by our clinical personnel using EsoCheck. Since then, additional testing events have been hosted
with the SAFD, and many similar events have been held with fire departments throughout the country. These events are ongoing and are
an extension of Lucid’s satellite test center program, which brings our precancer testing directly to patients—at their
physician’s office and now at testing day events.
In
March 2023, we launched a Direct Contracting Strategic Initiative (“DCSI”) to engage directly with large Administrative Services
Only (“ASO”) self-insured employers, unions and other entities, seeking to replicate the successes of other cancer screening
diagnostic companies that have deployed similar strategies. In August 2023, we contracted with the Ancira Automotive
Group as a result of this initiative, providing access to esophageal precancer testing for its employees at all 12 San Antonio locations.
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
final Local Coverage Determination (“LCD”) L39256, entitled “Molecular Testing for Detection of Upper Gastrointestinal
Metaplasia, Dysplasia, and Neoplasia” became effective in May 2023 on the Center for Medicare and Medicaid Services (“CMS”)
website by MAC Palmetto GBA. (A substantially identical LCD was published by Noridian Healthcare Solutions, the MAC whose geographic
jurisdiction covers our CLIA laboratory in Lake Forest, CA.) The LCD outlines criteria for future coverage 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 LCD indicated that it found that no currently existing
test has fulfilled all these criteria, it indicated that it will “monitor the evidence and may revise this determination based
on the pertinent literature and society recommendations.” We expect to submit EsoGuard for Technical Assessment under this foundational
LCD later this year.
In
parallel with preparing to submit EsoGuard for Technical Assessment with MolDX, 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 and continues to receive out-of-network commercial insurance payments for the EsoGuard test, which accounts for the vast
majority of our revenue to date.
Additionally, the legislatures in
a number of states have passed laws mandating coverage of comprehensive biomarker testing over the past several years. We believe that
EsoGuard falls within the definition of a biomarker test and thus we are reviewing how to leverage legislation in those states to expand
access to EsoGuard.
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.
Lucid
continues to expand the EsoGuard and EsoCheck evidence portfolio with additional clinical utility, clinical validity, and analytical
validity data from a range of ongoing studies and those that have recently completed or will be completed in the upcoming year. These
efforts include planned publication of the results from the previously discussed “Multi-center, Single-arm EsoGuard clinical validation
study” (“BE-1”) which will also be presented at Digestive Disease Week (DDW) 2024; this third clinical validation study
evaluated EsoGuard performance in the intended-use population. Publication of real-world experience of EsoCheck as a nonendoscopic cell
collection device is also planned (previously presented as a poster at DDW 2023), in addition to results from EsoGuard analytical validation
studies performed by LucidDx Labs, and a summary of real-world outcomes from several hundred patients who tested positive with EsoGuard
and underwent confirmatory endoscopic evaluation. These four manuscripts will be submitted for peer review in the first half of 2024.
The
Lucid-sponsored multi-center, prospective, observational CLinical Utility of EsoGuard study (CLUE) with >500
subjects completed enrollment in late 2023, and full results are expected to be published in mid-2024; results from an additional data
snapshot of the Lucid-sponsored PREVENT and PREVENT-Firefighter (FF) registries with a combined enrollment
of >1,000 subjects are expected to be published in a similar timeframe. Both studies capture information on the diagnostic and/or
therapeutic journey of subjects following EsoGuard testing, and in addition to provider decision impact, will contribute differing levels
of clinical outcomes data to the Lucid evidence portfolio.
Similarly,
results for the Lucid-sponsored virtual-patient study are expected to be ready for analysis in mid-2024.
Finally,
the “EsoGuard case-control study” (“BE-2”), a Lucid-sponsored clinical validation study, resumed enrollment in
2023 and is expected to continue through 2024. This data will further supplement what has previously been produced by the two NCI-funded
studies (Moinova, et al. Sci Transl Med. 2018; BETRNet).
Manufacturing
EsoCheck
is currently manufactured for us by our partners Coastline International (“Coastline”), a high-volume device manufacturer,
and Sage Product Development. Our current line at Coastline 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 CWRU (as amended to date, the “Amended CWRU License Agreement”), 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.
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 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.
In
October 2023, FDA proposed a policy under which FDA intends to phase out its general enforcement discretion approach for LDTs so that
IVDs manufactured by a laboratory would generally fall under the same enforcement approach as other IVDs. If finalized, FDA believes
that this phaseout may also foster the manufacturing of innovative IVDs for which FDA has determined there is a reasonable assurance
of safety and effectiveness. As such, FDA has structured the proposed phaseout policy to contain five key stages:
It
is currently anticipated that FDA will finalize the proposed policy by April 2024. Once the final policy is released, we will implement
the QS requirements in the recommended staged approach and conduct pre-submission meetings with FDA to seek agreement on regulatory pathway
for EsoGuard premarket submission. As required by the final policy, we will submit the regulatory premarket submission to the FDA as
per the timeframe defined in the final policy. We are confident that the proposed policy will not have a commercial impact as the Company
already has a robust QS management platform for medical devices and EsoGuard will be able to transition to the platform to fulfill the
QS requirements, if and when required by the FDA.
Our
longer-term strategy is to secure a specific indication, based on published guidelines, for BE testing in certain at-risk populations
using EsoGuard on samples collected with EsoCheck. This use of EsoGuard together with EsoCheck as a testing 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 ResearchDx Inc.
(“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 February 10, 2023, 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”). LucidDx Labs and RDx
agreed to terminate the MSA RDx effective as of February 10, 2023, such that LucidDx Labs now operates the laboratory itself, which
the Company believes has improved the efficiency of the performance of the EsoGuard assay.
In
November 2023, LucidDx Labs launched EsoGuard 2.0, which uses multiplexing thereby allowing both genes to be interrogated on a single
DNA sample. The next-generation assay underwent rigorous analytical and clinical validation studies, including head-to-head comparisons
of multiplexed triplicate consensus versus singleplex techniques, consistent with CLIA standards. Clinical validation analysis demonstrated
improved sensitivity and specificity for the detection of esophageal precancer, having demonstrated enhanced assay performance and lower
costs in extensive validation studies.
Competition
The
U.S. market for esophageal cancer (i.e., EAC) and pre-cancer (i.e., BE, with or without dysplasia) testing is large, consisting of more
than 30 million at-risk individuals over the age of 50. Given the large market for pre-cancer testing, 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 testing 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, EndoSign, commercialized by Cyted, and much like Cytosponge and our own EsophaCap
before it, is a small mesh sponge within a soluble gelatin capsule that needs to reside 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 sample contamination
as the brush later passes regions of the upper esophagus and mouth. Our competitors may also be developing additional methods of detecting
esophageal cancer and pre-cancer that have not yet been announced.
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 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
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 designs and patents that would be the foundation for 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 by 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 Platform 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 Platform 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. The Veris Platform integrates directly with practices’ and systems’ Electronic
Health Record (“EHR”) systems, allowing care teams to easily view and interact with this data. We have also been 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 and as resources permit, we will resume further
development activities for the implantable to bring it to market. The implantable will seamlessly interact with the Veris Platform. These
technologies are the subject of multiple patent applications and one issued patent.
Market
Opportunity
In
2023, 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
We
are currently pursuing strategic partnerships with leading academic oncology systems, whereby we would become the exclusive digital health
solution for these institutions’ oncology departments. More broadly, in terms of our commercialization strategy, we have a software-as-a-service
recurring-revenue business model where we seek to generate 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 derive revenues from remote physiologic
monitoring (and, in the future, device implantation) under existing CPT codes. Veris also plans to build a commercialization model around
the oncology data it is collecting, as resources permit. 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.
Manufacturing
The
components comprising the Veris 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 PAVmed
at its Foxborough, MA location. Customer support is currently managed internally, while partnering with Zendesk for customer service
management.
Regulatory
The
Veris Platform 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, the Veris Platform 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 plan to make our 510(k) submission for the
implantable monitor, which could happen as early as late 2024, if and to the extent resources permit us to do so.
Competition
The
U.S. market for cancer patient care is large. There are many existing competitors in the remote physiological monitoring space, some
of which possess significantly greater financial and other resources and development capabilities than us. Our Veris Platform 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.
Incubator
Program
On March 21, 2024, the Company announced
that it has launched a wholly owned incubator, PMX, to complete development and commercialization of existing portfolio technologies,
including PortIO, EsoCure and CarpX. PMX and Hatch Medical, L.L.C. (“Hatch Medical”), a medical device incubator and technology
brokerage firm, have executed a joint venture agreement to advance the technologies.
Pursuant to the joint venture agreement,
PAVmed will assign PortIO, EsoCure and CarpX to its wholly owned incubator, PMX. Starting with PortIO, the Company will seek to independently
finance a separate subsidiary of the incubator to develop and commercialize each technology. Hatch Medical will provide strategic advisory
and brokerage services to the subsidiary to advance the technology through key milestones and, subsequently, seek to engage a strategic
partner to acquire, license or distribute the commercial product.
Although the incubator, PMX, may seek to expand its portfolio
with internal or externally sourced technologies in the future, its initial assets, as noted, will include the following products:
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.
Esocure
In
connection with our efforts to expand our presence in the EAC diagnostic market, we were 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.
Recent
Developments
Business
Series
Z Warrant Modification
On
December 4, 2023, the Company announced the extension of the Company’s Series Z Warrants, by 12 months, to April 30, 2025.
In addition, as a
result of the reverse stock split, described below, the Series Z Warrants became exercisable to purchase one whole share of common
stock of the Company at an exercise price of $24.00, which exercise price per whole share was further reduced to $23.48 as described
below under the heading “PAVmed Distribution of Lucid Diagnostics Common Stock to Shareholders”. The Company
recognized the incremental value associated with the Series Z Warrants modification for the term extension as a deemed dividend
charge of $1.8 million and as an increase of net loss available to common stockholders on the consolidated statements of operations
in 2023.
Reverse
Stock Split
On
December 7, 2023, the Company implemented a 1-for-15 reverse stock split of its common stock and reduced its authorized shares from 250,000,000
to 50,000,000, each in accordance with shareholder approval granted at a March 31, 2023 special meeting of the Company’s stockholders.
The Company filed an amended Certificate of Incorporation reflecting the reduction in authorized shares.
The
purpose of the reverse stock split was to regain compliance with the $1 minimum bid price requirement for continued listing on the Nasdaq
Capital Market. Indeed, on January 7, 2024, the Company received a letter from the Listing Qualifications Department of Nasdaq, stating
the Company had regained compliance with such requirement.
Management
Services Agreement/Payroll Benefits and Expense Reimbursement Agreement with Lucid Diagnostics
On March 22, 2024, PAVmed and Lucid
entered into an eighth amendment to the management services agreement between PAVmed and Lucid (“MSA”) to increase the monthly
fee thereunder from $0.75 million per month to $0.83 million per month, effective as of January 1, 2024. The amendment also reset the
maximum number of shares issuable under the agreement to 19.99% of the shares outstanding as of the date of the amendment.
On
January 26, 2024, in accordance with the MSA and the payroll, benefits and expense reimbursement agreement between PAVmed and Lucid (“PBERA”),
PAVmed elected to receive payment of approximately $4.7 million of fees and reimbursements accrued under the MSA and the PBERA through the issuance of 3,331,771 shares of Lucid’s common stock.
PAVmed
Distribution of Lucid Diagnostics Common Stock to Shareholders
On
February 15, 2024, the Company distributed by special dividend to the Company stockholders 3,331,747 shares of Lucid Diagnostics common
stock held by the Company. On such date, each PAVmed shareholder as of the January 15,
2024 record date received a stock dividend of approximately 38 shares of Lucid common stock for every 100 shares of PAVmed common stock
they held as of such date. The shares distributed were approximately equal to the number of shares of common stock that Lucid issued
to PAVmed on or about January 26, 2024 in satisfaction of certain intercompany obligations due to Lucid from PAVmed, as discussed above.
This
distribution constituted an “Extraordinary Dividend” as defined in the warrant agreement that governs the Company’s
Series Z Warrants. As a result, pursuant to the warrant agreement, the exercise price under the Series Z Warrants per full share of PAVmed
common stock was automatically decreased by $0.52 (the fair market value of 0.37709668 of a share of Lucid Diagnostics’ common
stock) to $23.48 per share.
Nasdaq
Notice
On
March 7, 2024, the Company received a notice from the Nasdaq Listing Qualifications Department stating that, for the preceding 30 consecutive
business days (through March 6, 2024), the market value of the Company’s listed securities (“MVLS”) had been below
the minimum of $35 million required for continued inclusion on the Nasdaq Capital Market under Nasdaq Listing Rule 5550(b)(2). The notification
letter stated that the Company would be afforded 180 calendar days (until September 3, 2024) to regain compliance. In order to regain
compliance, the Company’s MVLS must close at $35 million or more for a minimum of ten consecutive business days. The notification
letter also states that in the event the Company does not regain compliance prior to the expiration of the 180-day period, the Company
will receive written notification that its securities are subject to delisting. The Nasdaq notification has no effect at this time on
the listing of the Company’s common stock or Series Z warrants, and the stock and warrants will continue to trade uninterrupted
under the symbol “PAVM” and “PAVMZ”, respectively.
Incubator Program
On March 21, 2024, the Company announced
that it has launched a wholly owned incubator, PMX, to complete development and commercialization of existing portfolio technologies,
including PortIO, EsoCure and CarpX. PMX and Hatch Medical, L.L.C. (“Hatch Medical”), a medical device incubator and technology
brokerage firm, have executed a joint venture agreement to advance the technologies.
Pursuant to the joint venture agreement,
PAVmed will assign PortIO, EsoCure and CarpX to its wholly owned incubator, PMX. Starting with PortIO, the Company will seek to independently
finance a separate subsidiary of the incubator to develop and commercialize each technology. Hatch Medical will provide strategic advisory
and brokerage services to the subsidiary to advance the technology through key milestones and, subsequently, seek to engage a strategic
partner to acquire, license or distribute the commercial product.
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 12, 2024,
the Company entered into an amendment and waiver (the “Note Amendment and Waiver”) with the holder of the April 2022 Senior
Convertible Note and the September 2022 Senior Convertible Note (each such term as defined below). Pursuant to the Note Amendment and
Waiver, the maturity date of the April 2022 Senior Convertible Note was extended to April 4, 2025 and the maturity date of the September
2022 Senior Convertible Note was extended to September 8, 2025, in each case subject to further extension in certain circumstances. The
holder of the such note also waived, for the period commencing on December 1, 2023 and ending on August 31, 2024, the financial covenant
contained in such notes requiring that the ratio of (a) the outstanding principal amount of the notes, accrued and unpaid interest thereon
and accrued and unpaid late charges to (b) the Company’s average market capitalization over the prior ten trading days, not exceed
30%, and that the Company’s market capitalization not be less than $75 million. In consideration of the Note Amendment and Waiver,
the Company agreed to pay the holder of the notes $2,000,000 in cash (or in such other form as may be mutually agreed in writing) by April
25, 2024.
See
our accompanying consolidated financial statements Note 13, Debt, for further discussion of the SPA dated March 31, 2022 and the
senior convertible notes.
Lucid Diagnostics - Preferred Stock Offerings
On March 13, 2024, Lucid entered
into subscription agreements (each, a “Series B Subscription Agreement”) and exchange agreements (each, an “Exchange
Agreement”) with certain accredited investors (collectively, the “Series B Investors”), which agreements provided for
(i) the sale to the Series B Investors of 12,495 shares of Lucid’s newly designated Series B Convertible Preferred Stock, par value
$0.001 per share (the “Lucid Series B Preferred Stock”), at a purchase price of $1,000 per share, and (ii) the exchange by
the Series B Investors of 13,625 shares of Lucid’s Series A Convertible Preferred Stock, par value $0.001 per share (the “Lucid
Series A Preferred Stock”), and 10,670 shares of Lucid’s Series A-1 Convertible Preferred Stock, par value $0.001 per share
(the “Lucid Series A-1 Preferred Stock”), held by them for 31,790 shares of Lucid Series B Preferred Stock (collectively,
the “Lucid Series B Offering and Exchange”). Prior to the execution of the Series B Subscription Agreements and the Exchange
Agreements, Lucid entered into subscription agreements with certain of the Series B Investors providing for the sale to such investors
of 5,670 shares of Lucid Series A-1 Preferred Stock, at a purchase price of $1,000 per share, which shares the investors immediately agreed
to exchange for shares of Lucid Series B Preferred Stock pursuant to the Exchange Agreements (and are included in the 10,670 shares of
Lucid Series A-1 Preferred Stock set forth above). Each share of the Lucid Series B Preferred Stock has a stated value of $1,000 and a
conversion price of $1.2444. The terms of the Lucid Series B 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 B Preferred Stock is
convertible, payable on the one-year and two-year anniversary of the issuance date. The Lucid Series B Preferred Stock is a voting security.
The aggregate gross proceeds to Lucid of these transactions was $18.16 million (inclusive of $5.67 million of aggregate gross proceeds
from the sale of the Lucid Series A-1 Preferred Stock that was immediately exchanged for Lucid Series B Preferred Stock in the transactions).
As a result of 100% of the then-outstanding
shares of Lucid Series A Preferred Stock and Lucid Series A-1 Preferred Stock being exchanged for shares of Lucid Series B Preferred Stock
in the Lucid Series B Offering and Exchange, no shares of Lucid Series A Preferred Stock or Lucid Series A-1 Preferred Stock remain outstanding.
On October 17, 2023, Lucid sold
5,000 shares of Lucid Series A-1 Preferred Stock, solely to accredited investors (all of which were including in the 10,670 shares of
Lucid Series A-1 Preferred exchanged for Lucid Series B Preferred Stock in the Lucid Series B Offering and Exchange). The aggregate gross
proceeds to Lucid of this offering was $5.0 million.
PAVmed
Inc. ATM Facility
In
December 2021, we entered into an “at-the-market offering” for up to $50 million of our common stock that may be offered
and sold under a Controlled Equity Offering Agreement between us and Cantor. In March 2023, the “at-the-market offering”
became subject to General Instruction I.B.6 of Form S-3, which limits sales of our securities under this instruction in any 12-month
period to one-third of the aggregate market value of our public float (unless our public float rises to $75 million or more, in which
case the instruction will cease to apply). As a result of this limitation and our then-current public float, in May 2023, we amended
our “at-the-market offering” to cover up to an additional $18 million of our common stock. In the year ended December 31,
2023, the Company sold 321,288 shares through its at-the-market equity facility for net proceeds of approximately $1.8 million, after
payment of 3% commissions.
Intellectual
Property
Our
business will depend proprietary medical device and diagnostic technologies to commercialize. We own or have the right to use intellectual
property rights, such as patents, trademarks, copyrights, trade secrets and know-how, pertaining to our EsoCheck and EsoGuard technology,
our Veris technology and our EsoCure, CarpX and PortIO products, among other technologies and products.
We
intend to vigorously protect our proprietary technologies’ intellectual property rights in patents, trademarks and copyrights,
as available through registration in the United States and internationally. Patent protection and other proprietary rights are thus essential