Item 1A. Risk Factors 11
Item 1B. Unresolved Staff Comments 21
Item 2. Properties 21
Item 3. Legal Proceedings 21
Item 4. Mine Safety Disclosure 21
Item 6. Reserved 22
Item 7A. Quantitative and Qualitative Disclosures About Market Risk 26
Item 8. Financial Statements and Supplementary Data F-1
Item 9A. Controls and Procedures 27
Item 9B. Other Information 27
Item 9C. Disclosures Regarding Foreign Jurisdiction that Prevent Inspections 27
PART III 28
Item 10. Directors, Executive Officers and Corporate Governance 28
Item 11. Executive Compensation 28
Item 14. Principal Accountant Fees and Services 28
Item 15. Exhibits and Financial Statement Schedules 29
Signatures 32
i
INTRODUCTORY
NOTE
Forward-Looking
Statements
This
report includes statements that are, or may be deemed, “forward-looking statements.” In some cases, these statements can
be identified by the use of forward-looking terminology such as “believes,” “estimates,” “anticipates,”
“expects,” “plans,” “intends,” “may,” “could,” “might,” “will,”
“should,” “approximately,” “potential” or negative or other variations of those terms or comparable
terminology, although not all forward-looking statements contain these words.
Forward-looking
statements involve risks and uncertainties because they relate to events, developments, and circumstances relating to Sensus Healthcare,
Inc., our industry, and/or general economic or other conditions that may or may not occur in the future or may occur on longer or shorter
timelines or to a greater or lesser degree than anticipated. Although we believe that we have a reasonable basis for each forward-looking
statement contained in this report, forward-looking statements are not guarantees of future performance, and our actual results of operations,
financial condition and liquidity, and the development of the industry in which we operate, may differ materially from the forward looking
statements contained in this press release, as a result of the following factors, among others: the continuation and severity of the
COVID-19 pandemic, including its impact on sales and marketing; our ability to achieve profitability; our ability to obtain and maintain
the intellectual property needed to adequately protect our products, and our ability to avoid infringing or otherwise violating the intellectual
property rights of third parties; the level and availability of government and/or third party payor reimbursement for clinical procedures
using our products, and the willingness of healthcare providers to purchase our products if the level of reimbursement declines; the
regulatory requirements applicable to us and our competitors; our ability to efficiently manage our manufacturing processes and costs;
the risks arising from our international operations; legislation, regulation, or other governmental action, that affects our products,
taxes, international trade regulation, or other aspects of our business; concentration of our customers in the U.S. and China, including
the concentration of sales to one particular customer in the U.S.; the performance of the Company’s information technology systems
and its ability to maintain data security; and other risks described from time to time in our filings with the Securities and Exchange
Commission.
In
addition, even if future events, developments, and circumstances are consistent with the forward-looking statements contained in this
report, they may not be predictive of results or developments in future periods. Any forward-looking statements that we make in this
report speak only as of the date of such statement, and we undertake no obligation to update such statements to reflect events or circumstances
after the date of this report, except as may be required by applicable law.
ii
PART
I.
Item
1. BUSINESS
Overview
Sensus
Healthcare, Inc. (together, with its subsidiary, unless the context otherwise indicates, “Sensus” or the “Company”)
is a medical device company committed to providing highly effective, non-invasive, and cost-effective treatments for both oncological
and non-oncological skin conditions. The Company uses a proprietary low-energy X-ray technology known as superficial radiation therapy
(“SRT”), which is based on over a decade of dedicated research and development, and has successfully incorporated SRT into
a portfolio of treatment devices: the SRT-100TM, SRT-100+TM and SRT-100 VisionTM. To date, SRT
technology has been used to effectively and safely treat oncological and non-oncological skin conditions in hundreds of thousands of
patients around the world.
On
February 25, 2022, the Company sold the assets comprising its SculpturaTM product for $15 million in cash. Additional information
regarding this transaction can be found in the Company’s Current Report on Form 8-K, filed with the Securities and Exchange Commission
on March 3, 2022.
Our
business was organized in 2010 and the Company, incorporated in Delaware, completed its initial public offering in 2016. The Company
operates as one segment from its corporate headquarters located in Boca Raton, Florida. For further information see Note 1, Description
of the Business, in the notes to the consolidated financial statements in Part II, Item 8.
Our
Products and Services
SRT-100
The
SRT-100 is a photon x-ray low energy superficial radiotherapy system that provides patients an alternative to surgery for treating non-melanoma
skin cancers, including basal cell and squamous cell skin cancers and other skin conditions such as keloids. The SRT-100 is especially
effective in treating primary lesions that would otherwise be difficult to treat or require extensive surgery involving sensitive areas
of the head and neck regions, such as the fold in the nose, eyelids, lips, corner of the mouth, and the lining of the ear, that would
otherwise lead to a less than desirable cosmetic outcome. Superficial radiation therapy treatment procedures do not require the use of
anesthetics and eliminate the need for skin grafting. The Company believes that the SRT-100 provides healthcare providers and patients
with a safe, virtually painless, and substantially non-scarring treatment option for non-melanoma skin cancer and other skin conditions,
such as keloids. It allows dermatologists to retain non-melanoma skin cancer patients, rather than referring them to specialists, while
offering radiation oncologists an alternative to costly linear accelerator–based treatments with a process that is less invasive,
more time-efficient, and improves practice economics. Revenue is primarily derived from sales of our SRT-100 product line. The SRT-100
provides the following clinical and functional advantages:
1
SRT-100
Vision
The
SRT-100 Vision provides customers with additional options compared to the SRT-100 base model. These additional options allow for dedicated
treatment planning and full treatment progression documentation in a patient’s record. The SRT-100 Vision provides the user with
a unique superficial radiation therapy-tailored treatment planning application that integrates an embedded high frequency ultrasound
imaging module, volumetric tumor analysis, beam margins planning, and comprehensive dosimetry parameters. This allows the user to precisely
and more accurately plan and prescribe the patient-specific treatment course to maximize patient outcomes and workflow efficiency. The
SRT-100 Vision also offers a comprehensive control console and workflow management that provides full record and treatment tracing, operator-level
access and functional control, audio-visual patient and treated lesion monitoring, and advanced dosimetry setting and tracing.
SRT-100
Plus
The
SRT-100+ offers all the same features as the SRT-100, with the addition of:
● An expanded energy range for customized, more precise treatment
● Remote diagnostics, including operation tracking
● New X-ray tube with extended functionality and performance
● Advanced console and enhanced system mobility to optimize clinical practice
Sentinel
service program
The
Company offers the Sentinel service program, which provides customers comprehensive protection for their systems. The Sentinel service
program covers all parts and labor for the period of the contract and one annual preventive maintenance session that includes cooling
system maintenance, high-voltage loop maintenance, filters and system cleaning, and system touch-ups, should these be required during
the preventative maintenance session.
Sensus
also provides turnkey pre-and post-sale services that include the following:
● Providing a pre-install kit for the contractors to prepare the treatment room;
● Room retrofit and shielding;
● System shipping coordination and installation;
2
Sensus
Laser Aesthetic Solutions (SLAS)
In
August 2020, the Company acquired two mobile aesthetic laser companies serving Florida: Aesthetic Mobile Laser Services, which serves
Southeast and Southwest Florida; and Aesthetic Laser Partners, which serves Central and Northern Florida. These companies, collectively
known as “Sensus Laser Aesthetic Solutions”, offer in-office laser rental services, providing an easy way for medical and
health care professionals to offer aesthetic laser procedures without the long-term financial commitment, maintenance, and obsolescence
concerns associated with equipment ownership. Sensus Laser Aesthetic Solutions delivers a complete line of aesthetic lasers to dermatologists
and clinicians around the state for a variety of treatments, both cosmetic and clinical.
Consumables
The
Company sells disposable lead shielding replacements, disposable radiation safety items, such as aprons and eye shields, ultrasound probe
film, and disposable applicator tips, which are used to treat various sized lesions and different areas of the body.
Competition
The
medical device industry is highly competitive and subject to rapid technological change and is significantly affected by new product
introductions and market activities of other participants. Current marketed products, and any future products that the Company commercializes,
will compete against healthcare providers who use other methods of treatment for the same disease or condition.
In
order to grow its business, Sensus must be able to compete effectively for market acceptance of its products. Key competitive factors
include improved outcomes for medical conditions, acceptance by doctors treating non-melanoma skin cancer and keloids, potential greater
acceptance by the patient community, potential greater ease of use and reliability, product price and qualification for reimbursement,
technical leadership and superiority, effective marketing and distribution, speed to market and quality of client service.
Sales
and Marketing
The
Company’s focus is mainly on two primary markets, private dermatology practices and radiation oncologists in both private and hospital
settings. The Company currently employs a multi-tier sales strategy to optimize geographic coverage and focus on its key markets. This
multi-tier sales model uses a direct sales force in the U.S., as well as international dealers and distributors. Sensus plans to continue
selling and marketing the Company’s products to both the dermatology and radiation oncology markets concurrently.
Dermatology
Market
Private
dermatology practices in the U.S. represent the point of entry for most non-melanoma skin cancer patients. The Company believes its SRT
products offer dermatologists a competitive advantage by allowing them to retain patients for the treatment of non-melanoma skin cancer,
rather than having to refer them to other professionals. In addition to non-melanoma skin cancers, the Company has had an FDA clearance
to treat keloid scars since 2014. The Company’s SRT has been used by over 100 U.S. dermatology practices in the treatment of keloids.
Since 2017, it is also being used to treat keloids in China.
Radiation
Oncology Market
For
licensed radiation oncologists in the U.S., the Company believes its SRT products offer a simpler, faster method of treatment with a
better overall patient experience. SRT offers oncologists the ability to free up more expensive radiation equipment, such as linear accelerators,
for more complex procedures while providing patients with effective, non-invasive treatment options for non-melanoma skin cancer.
3
Other
Markets
Sensus
believes that the plastic surgery and laser aesthetic markets present growth opportunities. With FDA clearance to treat keloids through
SRT, plastic surgeons are recognizing the opportunity to be able to provide an effective treatment solution for this benign tumor. Additionally,
the Company believes that plastic surgeons view the non-melanoma skin cancer market as a growth opportunity that can supplement their
existing services.
Global
Focus
As
of December 31, 2021, the Company had an installed base of 564 units in 18 countries, primarily in the United States. Customers include
leading cancer centers, dermatology practices, hospitals and plastic surgery clinics, which further validates the targeted marketing
approach led by the Company’s direct sales teams and global distribution partners.
Manufacturing
and Supply
The
Company currently uses third parties located in the U.S. to manufacture products. In 2010, the Company entered into a manufacturing agreement
with RbM Services, LLC (“RbM”) pursuant to which RbM agreed to manufacture SRT-100 products. Under this agreement, the Company
pays a fixed price per unit, subject to annual adjustments due to changes in the cost of materials. The agreement renews for successive
one-year periods unless either party notifies the other party in writing, at least 60 days prior to the anniversary date of the agreement,
that it will not renew the agreement. The Company or manufacturer may terminate the agreement upon 90 days’ prior written notice.
The
Company maintains internal policies, procedures and supplier management processes designed to ensure that RbM meets applicable quality
standards, including FDA and International Organization for Standardization, or ISO, requirements. To date, Sensus has not experienced
any difficulty in locating and obtaining the materials necessary to meet the demand for our products, and believes manufacturing capacity
is sufficient to meet global market demand for our products for the foreseeable future.
The
Company believes this third-party manufacturing relationship allows us to work with a supplier that has well-developed specific competencies
while minimizing our capital investment, controlling costs, and shortening cycle times, all of which has allowed us to compete effectively
with our competitors. Sensus also works with other third parties that it believes could be relied upon if there were a need to change
suppliers.
The
Company has a single preferred supplier for the x-ray tubes and other major components used in its products. The Company believes this
supplier has superior products; however, products of alternate suppliers would be adequate for Sensus’s products and therefore
the Company does not anticipate any material disruptions to the supply of major components if there were a change in suppliers.
Intellectual
Property
The
Company actively seeks to protect the intellectual property that is important to our business, including seeking and maintaining patents
that cover Sensus’s products. The Company also relies on trademarks to enhance, build, and maintain the integrity of the Sensus
brand.
4
The
Company is in the possession of several issued U.S. and Global patents. The patents relate to technology that is pertinent to the Company.
The
following patents were issued between August 2007 and September 2008:
The
following patents were issued to us in 2018:
The
following patent was issued to Sensus in 2019:
The
following patents were issued to Sensus in 2020:
A
total of 22 patent applications were pending at December 31, 2020 and additional patent applications are in process.
The
Company also owns seven U.S. trademark registrations (expiring from 2021 through 2031) and had two trademark applications pending as
of December 31, 2020.
The
Company also relies on trade secrets and other unpatented proprietary rights to develop and maintain a competitive position. The Company
seeks to protect unpatented proprietary rights through a variety of methods, including confidentiality agreements with employees, consultants
and others who may have access to this proprietary information. The Company requires all employees to execute invention assignment agreements
with respect to inventions arising from their employment.
The
Company can provide no assurance that any patents or trademarks will be issued or registered as a result of our pending or future applications
for such intellectual property. Even if any such patents or trademarks are ultimately issued or registered, they, or any of the Company’s
other intellectual property, may not provide any meaningful protection or competitive advantage. Intellectual property could be challenged,
invalidated, circumvented, infringed or misappropriated. In addition, third parties have claimed, and in the future may claim, that the
Company, customers, licensees or other parties indemnified by Sensus are infringing upon their intellectual property rights.
5
Government
Regulation
Sensus’s
business is subject to extensive federal, state, local, and foreign laws and regulations, including those relating to the protection
of the environment, health and safety. Some of the pertinent laws and regulations have not been definitively interpreted by the regulatory
authorities or the courts, and their provisions are open to a variety of subjective interpretations. In addition, these laws and regulations
and their interpretations are subject to change, and new laws may be enacted. Both federal and state governmental agencies continue to
subject the healthcare industry to intense regulatory scrutiny, including heightened civil and criminal enforcement efforts. The Company
believes that its business operations and relationships with customers and suppliers are structured to comply with all applicable legal
requirements. However, it is possible that governmental entities or other third parties could interpret these laws and regulations differently
and assert otherwise. Discussed below are statutes and regulations that are most relevant to the Company’s business. For the years
ended December 31, 2021 and 2020 we incurred approximately $1.3 million in expenses related to regulatory compliance and quality standards.
FDA
Regulation of Medical Devices
The
Federal Food, Drug and Cosmetic Act (“FDCA”) and FDA regulations establish a comprehensive system for the regulation of medical
devices intended for human use. Sensus’s medical device products are subject to these regulations, as well as other federal, state,
and local laws and regulations. The FDA is also responsible for the overall enforcement of quality, regulatory and statutory requirements
governing medical devices.
FDA
classifies medical devices into one of three classes — Class I, Class II, or Class III — depending on their level of risk
and the types of controls that are necessary to assure device safety and effectiveness. The class assignment determines the type of premarketing
submission or application, if any, that will be required before marketing in the U.S. The Company’s medical devices are Class II
devices under the FDA’s classification system. Class II devices are deemed to present a moderate risk and are devices for
which general controls alone are not sufficient to provide a reasonable assurance of safety and effectiveness. Medical devices in Class
II are subject to both general controls and “special controls” — e.g., special labeling, compliance with industry standards,
and post market surveillance. Unless exempted, Class II devices typically require FDA clearance before marketing, through the premarket
notification (“510(k)”) process, in accordance with 21 CFR, Part 807 requirements.
Unless
it is exempt from premarket review requirements, a medical device must receive marketing authorization from the FDA prior to being commercially
distributed in the U.S. The most common pathways for obtaining marketing authorization are 510(k) clearance and PMA. With the enactment
of the Food and Drug Administration Safety and Innovation Act (“FDASIA”), the availability of a de novo pathway
was facilitated for certain low- to moderate-risk devices that do not qualify for the 510(k) pathway due to the absence of a predicate
device.
510(k)
pathway
As
of December 31, 2021, all of our products were subject to or exempt from the 510(k) requirement. We have previously received FDA 510(k)
clearances for our SRT-100, SRT-100 Vision, and SRT-100+ products. The Company has obtained all of its FDA clearances through the 510(k)
pathway; although other pathways are available, the Company believes they are less efficient and effective for the Company.
Ongoing
FDA regulation
After
a device is entered into commerce in the U.S., regardless of its classification or premarket pathway, numerous additional FDA requirements
generally apply. These include:
6
The
FDA enforces these requirements by inspection and market surveillance. Failure to comply with applicable regulatory requirements can
result in enforcement action by FDA, which may include, but is not limited to, the following sanctions:
● Issuance of Form 483 observations during a facilities inspection;
● Untitled letters or warning letters;
● Fines, injunctions and civil penalties;
● Recall or seizure of products;
● Operating restrictions, partial suspension or total shutdown of production;
● Refusing 510(k) clearance or premarket approval of new products;
● Criminal prosecution.
The
Company is subject to unannounced establishment inspections by the FDA, as well as other regulatory agencies overseeing the implementation
of and compliance with applicable state public health regulations. These inspections may include our suppliers’ facilities.
International
Regulations
International
sales of medical devices are subject to foreign government regulations, which vary substantially from country to country. In order to
market our products in other countries, the Company must obtain regulatory approvals and comply with safety and quality regulations.
The time required to obtain approval by a foreign country may be longer or shorter than that required for FDA clearance or approval,
and the requirements may differ. The European Union/European Economic Area, or EU/EEA, requires a CE conformity mark in order to market
medical devices. The UK, due to Brexit, will also now require a separate clearance. Many other countries, such as Australia, India, New
Zealand, Pakistan and Sri Lanka, accept CE or FDA clearance or approval, although others, such as China, Brazil, Canada and Japan, require
separate regulatory filings.
In
the EU/EEA, Sensus’s devices are required to comply with the essential requirements of the EU Medical Devices Directive (93/42/EEC).
Compliance with these requirements entitles the Company to affix the CE marking of conformity to our medical devices, without which they
cannot be commercialized in the EU/EEA. To demonstrate compliance with the essential requirements and obtain the right to affix the CE
marking of conformity, the Company must undergo a conformity assessment procedure, which varies according to the type of medical device
and its classification. Except for low-risk medical devices (Class I), where the manufacturer can issue an EC Declaration of Conformity
based on a self-assessment of the conformity of its products with the essential requirements of the Medical Devices Directive, a conformity
assessment procedure requires the intervention of a Notified Body, which is an organization accredited by a Member State of the EU/EEA
to conduct conformity assessments. The Notified Body typically audits and examines the quality system for the manufacture, design and
final inspection of devices before issuing a certification demonstrating compliance with the essential requirements. Based on this certification,
we can draw up an EC Declaration of Conformity which allows us to affix the CE mark to our products.
7
Further,
the advertising and promotion of Sensus’s products in the EU/EEA is subject to the laws of individual EEA Member States implementing
the EU Medical Devices Directive, Directive 2006/114/EC concerning misleading and comparative advertising, and Directive 2005/29/EC on
unfair commercial practices, as well as other EU/EEA Member State laws governing the advertising and promotion of medical devices. These
laws may limit or restrict the advertising and promotion of our products to the general public and may impose limitations on our promotional
activities with healthcare professionals.
The
Company has obtained approval to sell our products in Australia, Canada, China, Europe, India, Israel, Mexico, Russia, South Africa,
South Korea, and Taiwan, and is currently seeking approval in several other countries.
Sales
and Marketing Commercial Compliance
Federal
anti-kickback laws and regulations prohibit, among other things, persons from knowingly and willfully soliciting, receiving, offering
or paying remuneration, directly or indirectly, in exchange for, or to induce either the referral of an individual, or the purchase,
order or recommendation of, any good or service paid for under federal healthcare programs such as the Medicare and Medicaid programs.
Possible sanctions for violation of these anti-kickback laws include monetary fines, civil and criminal penalties, exclusion from Medicare
and Medicaid programs, and forfeiture of amounts collected in violation of such prohibitions.
In
addition, federal false claims laws prohibit any person from knowingly presenting, or causing to be presented, a false claim for payment
to the federal government, or knowingly making, or causing to be made, a false statement to get a false claim paid. Off-label promotion
has been pursued as a violation of the federal false claims laws. Pursuant to FDA regulations, we can only market our products for cleared
or approved uses. Although surgeons are permitted to use medical devices for indications other than those cleared or approved by FDA
based on their medical judgment, we are prohibited from promoting products for such off-label uses. Additionally, the majority of states
in which we market our products have similar anti-kickback, false claims, anti-fee splitting and self-referral laws, which may apply
to items or services reimbursed by any third party payor, including commercial insurers, and violations may result in substantial civil
and criminal penalties.
To
enforce compliance with the federal laws, the U.S. Department of Justice, or DOJ, has increased its scrutiny of interactions between
healthcare companies and healthcare providers, which has led to an unprecedented level of investigations, prosecutions, convictions and
settlements in the healthcare industry. Dealing with investigations can be time- and resource-consuming. Additionally, if a healthcare
company settles an investigation with the DOJ or other law enforcement agencies, the company may be required to agree to additional compliance
and reporting requirements as part of a consent decree or corporate integrity agreement.
8
U.S. and foreign government regulators have increased regulation, enforcement,
inspections and governmental investigations of the medical device industry, including increased U.S. government oversight and enforcement
of the Foreign Corrupt Practices Act. Whenever a governmental authority concludes that a company is not in compliance with applicable
laws or regulations, that authority can impose fines, delay or suspend regulatory clearances, institute proceedings to detain or seize
the company’s products, issue a recall, impose operating restrictions, enjoin future violations and assess civil penalties against
the company, or its officers or employees and can recommend criminal prosecution. Moreover, governmental authorities can ban or request
the recall, repair, replacement or refund of the cost of devices the company distributes.
Additionally, the commercial compliance environment is continually evolving
in the healthcare industry as some states, including California, Massachusetts and Vermont, mandate implementation of corporate compliance
programs, along with the tracking and reporting of gifts, compensation and other remuneration to physicians. The Affordable Care Act also
imposes reporting and disclosure requirements on device manufacturers for any “transfer of value” made or distributed to prescribers
and other healthcare providers. Device manufacturers are also required to report and disclose any investment interests held by physicians
and their family members during the preceding calendar year. Failure to submit required information may result in civil monetary penalties
of up to an aggregate of $150,000 per year (and up to an aggregate of $1 million per year for “knowing failures”), for all
payments, transfers of value or ownership or investment interests not reported in an annual submission. The shifting compliance environment
and the need to build and maintain robust and expandable systems to comply in multiple jurisdictions with different compliance or reporting
requirements increases the possibility that a healthcare company may run afoul of one or more of the requirements.
Healthcare Fraud and Abuse
Healthcare fraud and abuse laws apply to Sensus’s business when a
customer submits a claim for an item or service that is reimbursed under Medicare, Medicaid or most other federally funded healthcare
programs. The federal Anti-Kickback Statute prohibits unlawful inducements for the referral of business reimbursable under federally funded
healthcare programs, such as remuneration provided to physicians to induce them to use certain tissue products or medical devices reimbursable
by Medicare or Medicaid. The Anti-Kickback Statute is subject to evolving interpretations. For example, the government has enforced the
Anti-Kickback Statute to reach large settlements with healthcare companies based on sham consultant arrangements with physicians. The
majority of states also have anti-kickback laws which establish similar prohibitions that may apply to items or services reimbursed by
any third party payor, including commercial insurers. Further, recently enacted amendments to the Affordable Care Act, among other things,
amend the intent requirement of the federal anti-kickback and criminal healthcare fraud statutes. A person or entity no longer needs to
have actual knowledge of this statute or specific intent to violate it. In addition, the Affordable Care Act provides that the government
may assert that a claim including items or services resulting from a violation of the federal anti-kickback statute constitutes a false
or fraudulent claim for purposes of false claims statutes. If a governmental authority were to conclude that we are not in compliance
with applicable laws and regulations, we and our officers and employees could be subject to severe criminal and civil penalties including,
for example, exclusion from participation as a supplier of product to beneficiaries covered by Medicare or Medicaid. In addition to the
Anti-Kickback Statute, the federal physician self-referral statute, commonly known as the Stark Law, prohibits physicians who have a financial
relationship with an entity, including an investment, ownership or compensation relationship, from referring Medicare patients for designated
health services, which include clinical pathology services, unless an exception applies. Similarly, entities may not bill Medicare or
any other party for services furnished pursuant to a prohibited referral. Many states have their own self-referral laws as well, which
in some cases apply to all third party payors, not just Medicare and Medicaid. If a governmental authority were to conclude that we are
not in compliance with the Stark Law or state self-referral laws and regulations, our business could be subject to severe financial consequences,
including the obligation to refund amounts billed to third party payors in violation of such laws, civil penalties and potentially also
exclusion from participation in government healthcare programs like Medicare and Medicaid. The Stark Law often is enforced through lawsuits
brought under the Federal False Claims Act, violations of which trigger significant monetary penalties and treble damages.
Additionally, the civil False Claims Act prohibits knowingly presenting
or causing the presentation of a false, fictitious or fraudulent claim for payment to the U.S. government. Actions under the False Claims
Act may be brought by the Attorney General or as a qui tam action by a private individual in the name of the government. Violations of
the False Claims Act can result in very significant monetary penalties and treble damages. The federal government is using the False Claims
Act, and the accompanying threat of significant liability, in its investigations of healthcare providers and suppliers throughout the
country for a wide variety of Medicare billing practices, and has obtained multi-million and multi-billion dollar settlements in addition
to individual criminal convictions. Given the significant size of actual and potential settlements, it is expected that the government
will continue to devote substantial resources to investigating healthcare providers’ and suppliers’ compliance with the healthcare
reimbursement rules and fraud and abuse laws.
9
Health Information Privacy
The federal Health Insurance Portability and Accountability Act of 1996,
or HIPAA, as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, or HITECH, and their respective
implementing regulations, impose requirements on certain covered healthcare providers, health plans and healthcare clearinghouses, known
as covered entities, as well as their business associates that perform services for them that involve individually identifiable health
information. The HIPAA privacy and security regulations, including the expanded requirements under HITECH, establish comprehensive federal
standards with respect to the use and disclosure of protected health information by covered entities and their business associates, in
addition to setting standards to protect the confidentiality, integrity and security of protected health information.
The Company has implemented policies and procedures related to compliance
with the HIPAA privacy and security regulations, as required by law. The privacy and security regulations establish a “floor”
and do not supersede state laws that are more stringent. Therefore, we are required to comply with both federal privacy and security regulations
and varying state privacy and security laws. In addition, for healthcare data transfers from other countries relating to citizens of those
countries, the Company must comply with the laws of those other countries. The federal privacy regulations restrict the ability to use
or disclose patient identifiable laboratory data, without patient authorization, for purposes other than payment, treatment or healthcare
operations (as defined by HIPAA), except for disclosures for various public policy purposes and other permitted purposes outlined in the
privacy regulations. HIPAA, as amended by HITECH, provides for significant fines and other penalties for wrongful use or disclosure of
protected health information in violation of the privacy and security regulations, including potential civil and criminal fines and penalties.
If the Company does not comply with existing or new laws and regulations related to protecting the privacy and security of health information,
it could be subject to monetary fines, civil penalties or criminal sanctions. In addition, other federal and state laws that protect the
privacy and security of patient information may be subject to enforcement and interpretations by various governmental authorities and
courts resulting in complex compliance issues. The Company could incur damages under state laws pursuant to an action brought by a private
party for the wrongful use or disclosure of confidential health information or other private personal information. If the Company were
to experience a breach of protected health information, it could be subject to significant adverse publicity in addition to possible enforcement
sanctions and civil damages lawsuits. Finally, the Company may be required to incur additional costs related to ongoing HIPAA compliance
as may be necessary to address evolving interpretations and enforcement of HIPAA and other health information privacy and security laws,
the enactment of new laws or regulations, emerging cybersecurity threats and other factors.
Research and Development
Research and development costs related to development and quality and regulatory
costs are expensed as incurred. For the years ended December 31, 2021 and 2020, the Company incurred research and development expense
of approximately $3.4 million and $4.2 million, respectively. Most of the decrease in R&D spending in 2021 was related to the final
development and production ramp-up of SculpturaTM.
Employees and Human Capital
At December 31, 2021, Sensus had 37 employees, including 33 in the U.S.
and four in Israel. None of the Company’s employees are represented by a labor union or covered by a collective bargaining agreement.
10
The Company believes that its success depends on the ability to attract,
develop, and retain key personnel. It also believes that the skills, experience, and industry knowledge of its key employees significantly
benefits its operations and performance. The Company believes that it offers competitive compensation and other means of attracting and
retaining key personnel.
Employee health and safety in the workplace is one of the Company’s
core values. The COVID-19 pandemic has underscored for the Company the importance of keeping employees safe and healthy. In response to
the COVID-19 pandemic, the Company has taken actions aligned with the World Health Organization and the Centers for Disease Control and
Prevention in an effort to protect the Company’s employees so they can more safely and effectively perform their work. These actions
include shutting down its headquarters for some months during 2020, providing facemasks to all employees, and allowing employees to work
from home.
Employee levels are managed to align with the pace of business and management
believes it has sufficient human capital to operate its business successfully.
Available Information
Sensus files annual, quarterly and current reports, proxy statements and
all amendments to these reports and other information with the SEC. Sensus makes available free-of-charge, on or through its website at
http://www.sensushealthcare.com, the Company’s Annual Reports on Form 10-K, Quarterly Reports on Form 10-Q, Current Reports on Form
8-K, proxy statements and all amendments to those filings, as soon as reasonably practicable after such material is electronically filed
with or furnished to the SEC . The information on the Company’s website is not incorporated by reference in this Annual Report on
Form 10-K. Reports, proxy statements and other information regarding issuers that file electronically with the SEC, including Sensus’s
filings, are also available to the public from the SEC’s website at http://www.sec.gov.
Item 1A.RISK FACTORS
An investment in Sensus’s common stock contains a high degree of
risk. Investors should carefully consider the following risks and uncertainties before making an investment decision with respect to our
common stock. Our business, including our operating results and financial conditions, could be harmed if any of these risks, as well as
other risks not currently known to us or that we currently deem immaterial, were to materialize. The trading price of Sensus’s common
stock could decline due to the occurrence of any of these risks. In assessing these risks, investors should also refer to the other information
included in our filings with the SEC, including our financial statements and related note.
Risks Related to our Business
If third-party payors do not provide coverage and adequate reimbursement
for the use of our products, it is unlikely that our products will be widely used, and our revenue will be negatively impacted.
In the U.S., the commercial success of Sensus’s existing products
and any future products will depend, in part, on the extent to which governmental payors at the federal and state levels, including Medicare
and Medicaid, private health insurers, and other third-party payors provide coverage for and establish adequate reimbursement levels for
procedures using these products. Neither hospitals nor physicians are likely to use Sensus’s products if they do not receive adequate
reimbursement payments for the procedures using these products.
Some private payors in the U.S. may base their reimbursement policies on
the coverage decisions determined by the Center for Medicare & Medical Services, or CMS, which administers the Medicare program and
works in partnership with state governments to administer the Medicaid program. Others may adopt different coverage or reimbursement policies
for procedures performed using Sensus’s products, while some governmental programs, such as Medicaid, have reimbursement policies
that vary from state to state, some of which may not pay an amount that supports the selling price of Sensus’s products, if at all.
A Medicare national or local coverage decision denying coverage for any of the procedures performed using the Company’s products
could result in private and other third-party payors also denying coverage. Medicare (Part B) and a number of private insurers in the
U.S. currently cover and pay for both non-melanoma skin cancer and keloid treatments using the SRT-100. A withdrawal, or even contemplation
of a withdrawal, by CMS, Medicaid or private payors of reimbursements, or any other unfavorable coverage or reimbursement decisions by
government programs or private payors, could have a material adverse effect on the Company’s business.
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Reimbursement systems in international markets vary significantly by country
and by region within some countries, and reimbursement approvals must be obtained on a country-by-country basis. In many international
markets, a product must be approved for reimbursement before it can be cleared for sale in that country. Further, many international markets
have government-managed healthcare systems that control reimbursement for new devices and procedures. In most markets there are private
insurance systems as well as government-managed systems. Sensus’s products may not be considered cost-effective by international
third-party payors or governments managing healthcare systems. Furthermore, reimbursement may not be available or, if available, third-party
payors’ reimbursement policies may adversely affect the Company’s ability to sell products profitably. If sufficient coverage
and reimbursement are not available for Sensus’s products, in either the U.S. or internationally, the demand for these products
and, consequently, the Company’s revenues, will be adversely affected.
Our business, results of operations, and
financial condition could be materially adversely affected by the effects of widespread public health epidemics, including COVID-19, that
are beyond our control.
Outbreaks of contagious diseases, public health
epidemics, and other adverse public health developments in countries where we, our customers, or our suppliers operate have had and could
have a material and adverse effect on our business, results of operations and financial condition. The COVID-19 pandemic has impacted
our sales as social distancing and related concerns forced physicians to temporarily close their practices in 2020. The pandemic is expected
to continue to adversely impact our business, and the nature and extent of the impact is highly uncertain and beyond our control. Uncertain
factors relating to COVID-19 include the duration, spread and severity of the virus, including the emergence of new variants, the effects
of the COVID-19 pandemic on our customers, vendors and suppliers, and the actions or perception of actions that may be taken to contain
or treat its impact, including declarations of states of emergency, business closures, manufacturing restrictions and prolonged restrictions
on travel, commercial and other activities.
In addition, as a result of COVID-19 and the measures
designed to contain its spread, our suppliers may not have the materials, capacity, or capability to manufacture our products according
to our schedule and specifications. If our suppliers’ operations are impacted, we may need to seek alternate suppliers, which may
be more expensive, may not be available, or may result in delays in shipments to us and subsequently to our customers, each of which would
affect our results of operations. The duration of the related financial impact to us, cannot be estimated at this time. Should such disruption
continue for an extended period of time, the impact could have a material adverse effect on our business, results of operations and financial
condition.
The Company’s operations may be impaired if information technology
systems fail to perform adequately or if are the subject of a data breach or cyberattack.
The Company’s information technology systems are critically important
to operating business efficiently. Sensus relies on information technology systems to manage business data, communications, employee information,
and other business processes. The Company outsources certain business process functions to third-party providers and similarly relies
on these third parties to maintain and store confidential information on their systems. The failure of these information technology systems
to perform as the Company anticipates could disrupt business and could result in transaction errors, processing inefficiencies, and the
loss of sales and customers, causing business and results of operations to suffer.
The Company has experienced, and expect to continue to experience, cyber
security threats and incidents, none of which has been material to Sensus to date. Although Sensus protects our information technology
systems, Sensus has experienced varying degrees of cyber-incidents in the normal conduct of business, including viruses, worms, phishing
and other malicious activities. Although there have been no serious consequences to date, such breaches could result in unauthorized access
to information, including customer, supplier, employee, or other company confidential data. Sensus carries insurance against these risks,
perform penetration tests from time to time, and designs business processes to attempt to mitigate the risk of such breaches. However,
the Company’s efforts to mitigate these risks may be unsuccessful, and security breaches may occur. Moreover, the development and
maintenance of these measures requires continuous monitoring as technologies change and efforts to overcome security measures evolve.
However, a successful breach or attack could have a material negative impact on operations and subject the Company to consequences such
as direct costs associated with incident response.
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If our essential employees who are unable to “telework”
become ill or otherwise incapacitated, our operations may be adversely impacted.
Consistent with rapidly changing federal, state and local governmental
orders and recommendations, we have implemented informal telework policies for appropriate categories of our employees. Employees that
are unable to telework continue to work at our facilities, and we have implemented appropriate safety measures, including social distancing,
face covering mandates, temperature checking, and increased sanitation standards in an attempt to maintain the health and safety of our
workforce. We are following guidance from the Centers for Disease Control and Prevention (“CDC”) and the Occupational Safety
and Health Administration (“OSHA”) regarding suspension of nonessential travel, self-isolation recommendations for employees
returning from certain geographic areas, confirmed reports of any COVID-19 diagnosis among our employees, and the return of such employees
to our workplace. Pursuant to updated guidance from the Equal Employment Opportunity Commission, we are engaging in limited and appropriate
inquiries of employees regarding potential COVID-19 exposure, based on the direct threat that such exposure may present to our workforce.
We continue to address other unique situations that arise among our workforce due to the COVID-19 pandemic on a case-by-case basis. While
we believe that we have taken appropriate measures to ensure the health and wellbeing of our employees, there can be no assurances that
our measures will be sufficient to protect our employees in our workplace or that they may not otherwise be exposed to COVID-19 outside
of our workplace. If a number of our essential employees become ill, incapacitated or are otherwise unable to continue working during
the current or any future epidemic, our operations may be adversely impacted.
Substantially all of Sensus’s revenue is generated from the
sale of the SRT-100 and related products, and any decline in the sales of these products will negatively impact the Company’s business,
financial condition and results of operations.
The Company is focused heavily on the development and commercialization
of a limited number of products for the treatment of non-melanoma skin cancer and other skin conditions with superficial radiotherapy.
From the Company’s inception in 2010 through December 31, 2021, revenue has primarily been derived from sales of the SRT-100 product
line and related services and ancillary products. Although Sensus has introduced new products, the Company expects most of revenue in
the near to medium term to be derived from or related to sales of the SRT-100 product line.
The Company’s technology could be superseded by new products,
treatments, or technologies that gain wider acceptance among doctors and patients, which could adversely affect the Company.
The medical device industry is highly competitive and subject to rapid
technological change, and is significantly affected by new product and treatment introductions. The Company’s products, some of
which use technologies that have been available for many years, compete for market acceptance against those of healthcare providers who
use other methods of treatment for similar diseases and conditions. If new products, treatments, and/or technologies were developed that
gain wide acceptance among doctors and patients, it could take market share away from the Company, which could adversely affect the Company’s
ability to maintain or increase revenue and/or render the Company’s products obsolete.
Sensus has a single preferred supplier for the x-ray tubes and other
major components used in the Company’s products and the loss of this preferred supplier could adversely affect the Company.
Sensus has a single preferred supplier for the x-ray tubes and other major
components used in the Company’s products. Although other suppliers exist in the market, the Company believes that our preferred
supplier’s products are of a superior quality. The loss of the preferred supplier, or its inability to supply the Company with an
adequate supply of these components, could hinder the Company’s ability to effectively produce the Company’s products to meet
existing demand levels, especially if Sensus were unable to timely procure them from other suppliers in the market, which could adversely
affect the Company’s ability to commercialize products and to maintain or increase revenues.
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The Company’s customers are concentrated in the U.S. (including
one U.S. customer accounting for a significant portion of our sales), and economic difficulties or changes in the purchasing policies
or patterns of the Company’s customers in these countries could have a significant impact on future business and operating results.
Most of the Company’s sales have been made to customers located in
the U.S. (95% and 97% in the years ended December 31, 2021 and 2020, respectively). Additionally, a single customer in the U.S. accounted
for approximately 57% and 40% of revenues for the years ended December 31, 2021, and 2020, respectively. Because of these concentrations,
revenue could fluctuate significantly due to changes in economic conditions, competitive products, or the loss of, reduction of business
with, or less favorable terms with, our significant customer or other U.S. customers. A reduction or delay in orders for the Company’s
products for these or other reasons could materially harm business and results of operations, including any adverse impact of the coronavirus
epidemic.
Sensus may be required to obtain additional funds in the future,
and these funds may not be available on acceptable terms or at all.
Sensus’s operations have consumed substantial amounts of cash since
inception. Sensus may need to seek additional capital, as our existing financial resources including our revolving line of credit, may
not allow the Company to conduct all of the activities that would be beneficial for future growth.
The Company may need to seek funds in the future. The Company’s existing
revolving line of credit restricts the ability to incur certain indebtedness or permit certain encumbrances on assets without the prior
written consent of the lender. If Sensus is unable to raise funds on favorable terms, or at all, the Company may not be able to support
commercialization efforts, increase research and development activities, meet debt and other contractual obligations, and the growth of
business may be negatively impacted. As a result, Sensus may be unable to compete effectively.
The Company’s cash requirements in the future may be significantly
different from current estimates and depend on many factors, including:
● the results of commercialization efforts for products;
● the need for additional capital to fund development programs;
● success in entering into collaborative relationships with other parties.
To the extent that Sensus raises additional capital through the sale of
equity or convertible debt securities, the ownership interests of the existing stockholders will be diluted. Moreover, the terms of newly
issued securities may include liquidation or other preferences that adversely affect common stockholders’ rights. Debt financing,
if available, may involve covenants limiting or restricting our ability to take specific actions such as incurring additional debt, making
capital expenditures or declaring distributions or dividends. If Sensus raises additional funds through collaboration and licensing arrangements
with third parties, the Company may have to relinquish valuable rights to technologies or products or to grant licenses on terms that
are not favorable. Any of these events could adversely affect the ability to declare dividends on the Company’s common stock and
to achieve future product development and commercialization goals and could have a material adverse effect on our business, financial