Good afternoon. My name is Catherine, and I will be your conference operator today. At this time, I would like to welcome everyone to the Nevro's Fourth Quarter 2020 Financial Results Conference Call. [Operator Instructions]. I would now like to turn the call over to Julie Dewey for introductory remarks. Thank you. Please go ahead..

Good afternoon, and welcome to Nevro's Fourth Quarter 2020 Earnings Conference Call. We appreciate you joining it. I'm Julie Dewey, Nevro's VP of IR and Corporate Communications. With me today are Keith Grossman, Chairman, CEO and President; and Rod MacLeod, Chief Financial Officer.

The format of our call today will be a discussion of fourth quarter trends and business results from Keith, followed by detailed financials from Rod, and then we'll open up the call for questions.

Please note, there are also slides available related to our fourth quarter performance on the Nevro Investor Relations website on the Events and Presentations page. Earlier today, Nevro released its financial results for the fourth quarter ending December 31, 2020.

A copy of our earnings release is available on our Investor Relations section of our website at nevro.com. This call is being broadcast live over the Internet to all interested parties on February 24, 2021, and an archived copy of this webcast will be available on our Investor Relations website.

Before we begin, I'd like to remind everyone that comments made on today's call may include forward-looking statements within the meaning of federal securities laws. Our results could differ materially from those expressed or implied as a result of certain risks and uncertainty.

Please refer to our SEC filings, including our Form 10-K to be filed later today for a detailed presentation of risks. The forward-looking statements in this call speak only as of today, and we undertake no obligation to update or revise any of these statements.

In addition, we will refer to adjusted EBITDA, which is a non-GAAP measure that is used to help investors understand Nevro's ongoing business performance. Please refer to GAAP to non-GAAP reconciliation tables within our earnings release. And now I'll turn the call over to Keith..

Thanks, Julie. Hello, everyone, and thank you for joining us. Today, we reported fourth quarter 2020 worldwide revenue of $109.7 million, representing a decline of 4% compared to the fourth quarter of 2019. On a sequential basis, worldwide revenue increased 1% over the prior quarter. U.S.

sales declined 3% over the prior year to $94.6 million in the fourth quarter, but increased 4% sequentially over the prior quarter. International revenue decreased 8% year-over-year as reported or 14% on a constant currency basis with -- to $15.1 million in the fourth quarter, and that represents a sequential decline of 14% over the prior quarter.

Both U.S. and international revenue was meaningfully impacted by the resurgence of COVID activity in the second half of the quarter. U.S. trials per day, perms per day and revenue, all improved over Q3 results despite the increase in COVID activity.

Now while encouraging, it's important to note that activity started stronger at the beginning of the quarter and degraded over the course of the quarter as COVID activity increased. Compared to prior year fourth quarter, total U.S. permanent implant procedures decreased 1%, with trial procedures declining 8%. Approximately 200 scheduled U.S.

permanent implant procedures, or roughly $5 million in sales, were canceled and still unrecovered at the end of the fourth quarter, with the majority of those occurring in the month of December.

Reductions in both trials and perms in the quarter were caused by a combination of a facility reduction of electric procedures, patient reluctance to move forward due to COVID concerns or the exposure or diagnosis of health care providers with the COVID virus themselves.

Throughout 2020, and despite the impact on our business of COVID, we delivered strong progress across our business. First, we maintained our workforce during an unprecedented and challenging pandemic environment and enabled our Nevro team to do their job safely, in most cases, virtually and effectively.

We also added key members to our leadership team. Our field team continued to support our customers and patients' side-by-side with frontline health care workers and patients.

We used our unique Nevrocloud capabilities to reach out to patients and have now had over 800,000 remote patient interactions throughout the challenges of the COVID environment, both optimizing therapy for our patients and getting canceled cases back on the calendar for our customers faster than our competitors could.

We continued to capture share in our U.S. market throughout 2020 and expanded our competitive advantage with the ongoing Omnia launch. In fact, over the combined course of 2019 and 2020, we think we've picked up 4 to 5 U.S. market share points.

Our R&D and clinical teams prioritize and advance future products and indication growth drivers including the first major upgrade to our Omnia platform, which you'll hear more about later in this call.

On the intellectual property front, we were successful in our offensive litigation against both Boston Scientific and Stimwave, maintaining exclusivity for high-frequency SCS therapy. We completed a successful capital raise within weeks of the onset of COVID, adding over $300 million to our balance sheet.

And demonstrated prudent expense management throughout the year, delivering adjusted EBITDA positive performances in both the third and the fourth quarters.

We kicked off a project to establish our own manufacturing operations in Costa Rica, and we expect to be approved to make and sell our own products sometime next year, improving our cost position and our manufacturing flexibility.

Continuing our long-standing commitment to our growing body of clinical evidence, data from both our PDN and NSRBP randomized clinical trials was accepted for the late-breaking abstract session at NANS, positioning us to help physicians treat new and underserved patient population suffering from debilitating chronic pain.

We ended the year on a high note by announcing our FDA submission to seek approval for the treatment of chronic pain associated with PDN. This condition affects millions of patients who are suffering today with no really good options. In any year, I think these are accomplishments that we would be proud of.

But in 2020, our team accomplished these goals during a global pandemic. And I want to thank the entire Nevro team for all what they did, not only respond to the pandemic but for keeping the company moving forward in spite of it. So let me update you on the current state of the COVID impact on our business.

As of today, COVID continues to impact patient demand, case scheduling and cancellation rates with procedures still strongly impacted as we're seeing in December.

We continue to think that this impact will diminish with each sequential quarter this year as vaccine availability improves, and patients begin to, again, seek elective care at a more typical pace. Rod will get into a bit more detail on what that means going forward from the standpoint of our guidance.

We believe many patients are continuing to defer treatment until they feel comfortable visiting a physician, particularly as they perceive a vaccine to be just around the corner.

Similar to the demand trends experienced in the second and third quarters of 2020, we expect the resurgence of COVID in the fourth quarter of 2020 and first quarter of this year will create another period of pent-up demand recapture as infection rates subside and vaccine availability improves and starts to positively affect patient behavior.

Now obviously, the timing and size of the recovery is really difficult to predict.

While the environment continues to be a difficult one today, on a relative basis, we believe we continue to capture market share in the core lower back and leg pain market throughout 2020 as a result of our best-in-class HF10 SCS technology, our expanded Omnia platform, new and important indications and sharpened commercial execution.

And I really believe we're well positioned for attractive and sustainable growth as the pressure of COVID on our business subsides.

We had another terrific NANS conference this year with data presented from 20 clinical abstracts, including late-breaking abstract results from our Senza PDN and Senza NSRBP randomized clinical trials, both of which demonstrated highly favorable results to nearly all prespecified endpoints at 6 and 12 months in the PDN study and 3 months of the NSRBP study.

No other SCS treatments have demonstrated such positive results in treating these patient populations, and we believe these are significant opportunities for Nevro. We announced that we submitted our PMA supplement to the FDA in December to seek approval for PDN, and that submission was accepted by the FDA in early January.

If approved, the Senza system would be the only spinal cord stimulation system FDA approved with a specific on label indication for treating PDN. And assuming a 6-month review cycle from acceptance, an approval from the FDA would also position us to initiate U.S. launch activities in the second half of 2021.

As a reminder, there are over 5 million patients in the U.S. diagnosed with PDN, and approximately 2 million of these patients are refractory to or failing conventional medical management and in need of a new solution to treat their chronic pain. That represents a roughly $47 billion prevalence pool in the U.S.

and an estimated annual incidence rate of approximately 5 billion. I have to say I'm about as excited for this launch as any I can remember. Our goal is to get off to a fast start in the second half of the year in referral and trialing activity, setting the stage for an exciting revenue impact in 2022.

And I'd like to spend a couple of minutes setting the stage for the rest of this year's PDN launch activities. We submitted our 6-month PDN trial results for publication, which have been accepted in a premier peer-reviewed journal. We plan to submit 12-month data later this year.

In addition, the health economic data will be analyzed and submitted for publication later this year along with real-world evidence from our Nevrocloud platform, analyzing the long-term outcomes of HF10 patients diagnosed with PDN. An important aspect of our launch is to ensure market access.

We've already started approaching payers with the goal of expanding policy coverage to include PDN patients where it doesn't exist today. So far, it seems the data will be compelling for those payers, particularly given this patient population, where they just haven't received much traction with other therapeutic options that they're paying for.

Part of our message to payers is that the quality of the clinical evidence and the outcomes reported as well as a potential FDA approval will all be unique to HF10 therapy and should be treated as such through their coverage policy decision-making.

We think there's already a meaningful percentage of patients that will have coverage at the time of our launch. Through local coverage determinations of the Medicare contractors or Mx, we estimate approximately 50% of Medicare beneficiaries should have access at launch.

On the commercial side, the majority of commercial health plans have not historically included PDN in their SCS coverage policy. So in aggregate, between the 2 groups, we estimate that roughly 25% of our PDN patients will have access at launch.

While some payers may require 12-month data, we expect to have that data by the time we receive FDA approval. With this in mind, we expect our commercial coverage to increase over time as additional commercial payers expand coverage throughout 2022.

Our research has shown that while pain physicians are very interested in treating PDN patients, they don't see a lot of them referred to them today. So education of those referring doctors will be a key part of our commercial launch. We've analyzed U.S. claims data and identify the doctors that are treating the most PDN patients today.

In the U.S., the top 1% of physicians ranked by PDN patients treated, which is around 2,200 doctors, treat approximately 10% of all PDN patients. And the top 10% of physicians treat approximately 21% of all PDN patients.

This relatively concentrated referring physician channel consists of primary care physicians, endocrinologists, internal medicine and podiatrist.

To reach these referring doctors, we will be staffing a dedicated referral sales organization as well as remote selling resources ready to begin calling on these referring doctors with the goal of educating them on the benefits of HF10 therapy and how their patients can access it.

In addition, we'll be driving awareness with the referring doctors via digital marketing programs. Our existing sales force who are now focused on the pain medicine community will also have informational tools and resources to provide to our pain physicians so that they may begin to conduct outreach within their own referring physician communities.

Our research found that referring physician enthusiasm for HF10 in PDN patients is very high. In fact, when presented with our trial data, 75% of referring physicians rated HF10 a 5 or 6 on a 6-point attractiveness scale for treatment of PDN. There's also a strong desire to use HF10 prior to prescribing opioids.

Our research indicates that physicians expect to refer nearly 90% of their refractory PDN patients for HF10 therapy before recommending opioids, providing hope of a new solution for the millions of patients suffering today.

We've also formed a PDN Advisory Board, which consists of a cross specialty of physicians to refine our initiatives help shape PDN clinical guidelines and advise on future study designs.

We plan to increase our presence on key diabetes conferences starting with this year's American Diabetes Association conference, to drive awareness, beginning with scientific abstract submissions and evolving to a broader footprint upon FDA approval. In addition, we've also completed research with PDN patients.

These patients are truly suffering and are desperate for new solutions. As one patient told us, "It got to the point where I couldn't tell what was worse, the pain or the side effects of my medication. I wasn't able to concentrate when the pain was there.

But if I took my medication, it was like I was a zombie, I wasn't even there." This settlement pretty [indiscernible] summarizes what we hear from the majority of the PDN patients that we speak with. About 84% of PDN patients we surveyed, said they would go see a pain specialist for HF10 therapy once referred.

We know that these diabetes patients take an active part in their care and are highly engaged online.

So we're building upon our success in direct-to-patient digital marketing to our back and leg market, and we're expanding that focus even now so that as many PDN patients as possible will already be informed by the time a new treatment option is available to them.

In summary, 2021 is about gaining FDA approval for PDN educating physicians that treat these underserved patients, driving awareness with the PDN patients themselves and facilitating payer coverage expansion.

Our 2021 investment in the activities I've listed and many others, by the way, will total approximately $22 million this year and will be included in the forward-looking details Rod provides in just a moment.

Because of the timing of the expected approval, and of course, the time needed to then move patients through the referral to trial to perm pathway, we expect only a mid-single-digit million revenue contribution from PDN in the back half of '21, and most of that will be in the fourth quarter.

But then setting us up for a broader penetration and much larger revenue contribution in 2022 and beyond. Internationally, we'll be executing phase launch plans in the U.K., Germany and Australia. We expect these activities to mirror U.S. timing and launch plans to expand as we progress into 2022.

So we're hoping for a really exciting year for this new indication. I'm also pleased to announce that we recently received FDA approval for our first major Omnia upgrade. If you recall, when we originally launched Omnia, one of the unique benefits was that the platform is upgradable.

So our patients can continue to get the benefit of innovation without requiring a brand-new IPG. We're launching a limited market release of this upgrade in March with a full market release in Q2 in the U.S. and Australia. We've also submitted our application for approval in Europe and expect to have clearance later in Q2.

Now this upgrade will give Omnia the ability to accept the loading of 35 programming options for a patient immediately after implant instead of the current limit of just 5.

This change, combined with the changes made to the new patient remote device, means that many of the future therapy adjustments that are now reprogramming events that need to be done in person by our field team can become a simple program selection by the patient, guided by one of our expanding team of therapy support specialists over the phone.

The 35 programs originally selected will be done under the oversight of our clinicians, as always. And the order in which a patient would be directed to select them in the future will be driven by the same Nevrocloud-informed algorithms that are used by our field personnel today.

Finally, the new upgraded patient remote will also include an auto impedence check feature. The impedence check is necessary to verify connection between the IPG and all of the electrodes on both leads. Currently, a member of our field team needs to be physically present.

This happens in the OR at the time of every implant when leads are connected to the IPG. The impedence check is also performed at a hospital or satellite imaging facility when any patient with one of our devices requires an MRI.

The new patient remote can eliminate the need for our sales rep to be there in person to perform either of these impedence checks. And by the way, these development projects kicked off just months ago, as part of our rapid response to the COVID challenges, and our team did a great job of bringing these upgrades to market in record time.

This new package of Omnia upgrades will not only help us to be more responsive to patient needs, but importantly, all of these changes are also going to make our sales team much more efficient over time and will be an important part of the efficiency with which we scale over the next few years.

We're also expecting to launch our new trial stimulator module in the first half of this year once it's approved. The new module is designed to provide improvements in patient comfort through a smaller, more streamlined, cable-free system that simply allows patients to focus more on their pain relief than the logistics of the trial system.

We're going to begin the early steps of developing the nonsurgical portion of our market using the new 3-month NSRBP data presented at NANS. Our work will start with surgeons, patients and payers.

And with 6- and 12-month data coming and our competitors eventually helping to push on this underpenetrated market, we think this patient group will help to drive SCS market growth in the coming years.

One of the areas I'm particularly proud of is our ability to manage expenses and drive operating leverage without eroding our team or our core capabilities to drive growth. Prior to the pandemic, we took steps to focus on our overall cost structure and placed an emphasis on improving operational efficiencies.

Even with the decline in revenue in 2020, our operating expenses, as a percent of revenue, dropped 700 basis points from 2019 levels. On a dollar basis, we were able to reduce operating expenses by more than $50 million compared to 2019.

While we expect operating expenses, particularly sales and marketing costs to increase as we emerge from the pandemic and continue investing in our PDN launch preparations, leveraging the income statement will continue to be a top priority.

So while we're certainly still in the midst of this pandemic, we do see a light at the end of the tunnel, and we remain very bullish on the longer-term growth drivers for this business.

First, a still underpenetrated SCS market that should continue to grow, we believe, for years to come; second, the pent-up demand of all those elective procedures that have been COVID-deferred over the last year, that we'll begin to see care again as the year progresses and COVID starts to recede.

If you look at where a healthy market should have been last year relative to 2019, those numbers suggest deferred procedures in the worldwide SCS market in 2020, represented as much as $500 million worth of product sales. We believe many of these patients will make their way back to SCS therapy in the quarters following COVID.

Third, our ability to continue to increase our share of this market over time with better technology, better outcomes and better execution. And fourth, market-expanding clinical data like NSRBP and new market creating indications like PDN.

As we think about our ultimate emergence from the pandemic, it should be the beginning of a really attractive growth period for this company.

And lastly, I want to, once again, express my appreciation and gratitude to the entire network team for their efforts throughout what was a very challenging 2020, which enabled us to deliver on our commitments to our customers, our patients, our employees and our shareholders. And with that, I'll pass the call over to Rod..

Thanks, Keith. I'll begin with our worldwide revenue for the fourth quarter of 2020, which is $109.7 million, a decrease of 4.1% compared to $114.4 million in the prior year period. Gross profit for the fourth quarter of 2020 was $78 million, a decrease of 4% compared to $81.3 million in the prior year period.

The decrease in gross profit was driven primarily by the year-over-year reduction in revenue. Gross margin in the fourth quarter was 71%, consistent with the prior year period. Operating expenses for the fourth quarter of 2020 were $78.9 million, a 15% decrease compared to $92.9 million in the prior year period.

The year-over-year decrease in operating expenses was primarily related to a decrease in clinical trial expenses related to our PDN and NSRBP studies, lower travel-related expenses, as well as management's continued initiatives to drive leverage throughout the business, which had begun well before COVID.

Fourth quarter operating expenses also benefited from accrued bonus expense, 401(k) match, payroll taxes and project expenses, all of which will be higher in the first quarter as we start the new year. Legal expenses associated with patent litigation were $5.1 million for the fourth quarter of 2020 compared to $1.7 million in the prior year period.

In December, we announced an agreement to conclude our patent lawsuit in the northern District of California against Boston Scientific. We continue our ongoing patent cases in the district of Delaware, and at the patent office relating to patents for other spinal cord stimulation technologies unrelated to high-frequency therapy.

Net loss from operations for the fourth quarter of 2020 was $900,000, a 93% improvement compared to a loss of $11.7 million in the prior year period. Non-GAAP adjusted EBITDA for the fourth quarter of 2020 was $15.7 million compared to $1.5 million in the prior year period.

Non-GAAP adjusted EBITDA excludes certain litigation expenses, interests, taxes, and noncash items such as stock-based compensation and depreciation and amortization. Please see our financial tables for GAAP to non-GAAP reconciliations.

During the pandemic, we continue to focus on cash preservation while balancing the need to reinvest in the recovery process and our growth initiatives in PDN and NSRBP. Cash, cash equivalents and short-term investments totaled $588 million as of December 31, 2020. This represents an increase during the fourth quarter of 2020 at $15.1 million.

Turning now to 2021 guidance. It's important to note that we will be using non-GAAP financial measures to describe our outlook for the business. Non-GAAP adjusted EBITDA excludes certain litigation expenses, interest, taxes and noncash items such as stock-based compensation and depreciation and amortization.

Once again, please see the financial tables in our press release issued today for GAAP to non-GAAP reconciliations. As Keith mentioned earlier, the impact of COVID coming into the first quarter of 2021 and is little changed thus far from the end of fourth quarter of 2020 as high case volumes and new variants add additional uncertainty.

Nevro expects first quarter of 2021 worldwide revenue of approximately $84 million to $86 million in sales. This assumes COVID headwinds in the first 2 months of the first quarter of 2021, with improvement beginning in March of 2021. The company expects operating expenses in the first quarter of 2021 of approximately $83 million to $86 million.

This includes litigation expenses and additional investment in PDN market development. As for the full year, it's clear that we and many other companies are struggling with the topic of if and how to provide 2021 guidance. Though we believe it is important to give you some visibility into how we are thinking about the totality of 2021 as well.

The full year guidance provided today is highly sensitive to the company's COVID recovery assumptions, which include an ongoing and steady recovery in the U.S. and key international geographies, leading to more normalized case scheduling, and elective procedure levels beginning in the second quarter of 2021.

This guidance also assumes the impact from COVID-19 will diminish with each sequential quarter this year as the vaccine availability improves and patients begin to again see collective care at typical levels.

Of course, if the vaccine rollout takes longer, recovery is delayed, or patient willingness to seek treatment is slower than anticipated, or alternatively, if recovery is faster or there is a larger recapture of pent-up demand than anticipated, then any or all of these factors could quickly and easily impact our guidance range.

With that in mind, we currently expect worldwide revenue for full year 2021 of approximately $430 million to $450 million. This range assumes FDA approval of PDN at the beginning of the third quarter of 2021 and a mid-single-digit million-dollar revenue contribution from PDN in 2021 with the majority generated in the fourth quarter.

For full year 2021, gross margin is expected to be approximately 69% as we will be incurring about 100 basis point impact to margins as we build out operations in the Costa Rica plant this year. We're very excited about the Costa Rica expansion. We believe it will deliver considerable leverage over the next several years.

Operating expenses are expected to be approximately $370 million for 2021. This includes litigation expenses and ongoing investment in PDN market development, which I will speak about shortly.

We expect full year 2021 non-GAAP adjusted EBITDA to be in the range of $0 to $15 million, which compares to a non-GAAP adjusted EBITDA loss of $3.9 million in 2020. We also want to provide some additional color regarding our commercial launch of PDN and its impact on the income statement.

We believe that these investments will drive some early revenue contribution from PDN in the third and fourth quarters of 2021, but more importantly, position us for a solid run rate of patient referrals and trials as we enter 2022.

On the expense side, we expect to spend approximately $22 million of operating expenses in 2021 to support a successful PDN launch as well as market development, with roughly 60% of the expenses occurring in the back half of this year.

Given the significant opportunity that PDN represents, we believe this investment is appropriate to support a successful launch and optimize growth in 2022 and beyond. Finally, I think it's important to review our progress on our journey to drive growth and scale profitably in our core business.

Let's look at our operating expenses as a percentage of revenue, for example. Over the years, operating expenses have gone from 93% of revenue in 2019 to 86% of revenue in 2020. And our guidance for 2021, excluding the $22 million of PDN expenses, suggests operating expenses of 73% to 76% of revenue for 2021.

Additionally, our 2021 expense assumptions even assume an additional $11 million of patent litigation expenses over 2020, which represents an additional $250 million basis points of leverage.

Many of the changes we're investing in this year, such as our integration of manufacturing, early development of the PDN market and the Omnia upgrade to facilitate greater commercial productivity are designed to provide continued improvement in our financial leverage as we grow.

We believe that with these investments, we can create even greater leverage in the coming years, though please keep in mind that even including all of the investments I have just mentioned, our total operating expenses would only be about 1% higher than those operating expenses in 2019.

In closing, we entered 2021 in a great position strategically with best-in-class SCS technologies, share gain momentum, future growth opportunities in PDN and NSRBP superior clinical data and a strong commercial organization.

We have made significant progress on our operating margin expansion efforts over the past year, and we have ongoing opportunities to continue to improve in this area as well as driving continued leverage in the business in 2021 and beyond. That concludes our prepared remarks. I'll turn the call back over to Julie to moderate the Q&A session..

Thanks, Rod. Before we start the Q&A session, we'd like to ask that you please limit yourself to one question and one short follow-up. Operator, we're ready for the Q&A instruction..

[Operator Instructions]. Your first question comes from the line of Adam Maeder with Piper Sandler..

And congrats on the progress made in 2020. I wanted to ask about latest trends and what you're seeing in the business -- what you saw in the business in January and thus far into February. It sounds like the environment is still remains a bit challenging.

So I wanted to better understand where permanent implants and trials sit today and how those have progressed year-to-date? Just any color there would be helpful. And then I had a follow-up..

Yes. Well, Adam, over the course of last year, we tried to give a little bit more intra-quarter color on things like trials because we were in a period of time where we didn't have a guidance in place. We've put guidance in place now for the quarter and the year.

So I want to be a little bit careful we don't get too deep into metrics for the month of January or December. But so let me speak a little bit more generally. I would say January probably started out about like December, maybe worse from just a general level of activity standpoint, numbers of trials, cancellations, et cetera.

February, marginally better despite the added complication of weather around the country in the U.S. And I would say early signs that things are going to begin getting better in March, though that's an expectation at this point, of course, not a reality.

So I would say, if you look at the December -- mid-December to end of January time frame, that was probably about the worst 6-week period for general activity in this therapy since probably the May to early June time frame of last year. So we don't certainly expect to ever see what we saw last March and April, again.

But there was an awful lot of complications, COVID-related complications around procedural activity, case cancellations, center close -- shutdowns, et cetera, that is starting to get better now here in the second half of February..

That's really helpful color, Keith. I appreciate that. And then for the follow-up, maybe to ask about NSRBP, I just wanted to ask for an update on how those conversations are going with payers, if you're seeing any positive read-throughs from the data that was presented at NANS. And I think historically, NSRBPs have been kind of around 30% of your mix.

So how do you think about the impact from the data this year? Does that mix increase? Just trying to understand if that's going to be a key tailwind in '21 or if it's more of a '22 and kind of medium- to longer-term benefit..

Yes. I think it's a little bit too early to say on payer feedback to NSRBP. We have probably gotten off to a little bit quicker start talking to payers about reactions to PDN.

I think in the case of NSRBP, while we will be having those payer meetings throughout the year, we recognize that most payers are going to want 6 or even 12-month data on the nonsurgical refractory back pain side of things. So more to come, maybe we can give you a little bit more of a reaction later in the year.

Certainly, our expectations for that population of patients has some impact on our expectations for this year. Generally, I think it's relatively small this year, and it begins to grow in 2022 and 2023..

Your next question comes from the line of Joanne Wuensch with Citibank..

This is Matt Henrickson [ph] in for Joanne. Keith, you gave some great color on just the kind of number of patients that have delayed but have been recoverable with procedures.

As we think about 2021 and we look at kind of that backlog being filled out, is there something along the lines where we're looking at kind of second half seeing a bolus of those backlog patients? Or do you expect that kind of faucet to open up immediately as kind of things subside?.

Well, that is the question of the day. That may be the question of the year. I think trying to predict when and why that -- and at what pace that begins to open up is the challenge in thinking about this year and the challenge that we face in providing guidance for this year.

I think in general -- we've done an awful lot with studying patients and physicians through market research, what they expect, what they plan to do. I think at this point, a lot of patients are really waiting for the vaccine. We saw in the first quarter a little bit more impact from centers. I think in early February, we had 90 hospitals in the U.S.

that had shut down electric procedures. Now that's not a big percentage of our hospitals, but it's not insignificant either. And we haven't seen really a center impact, an institution impact for quite some months. That's now beginning to show signs of opening back up.

But for the most part, this has been a patient issue and a patient reticence to seek care until the environment meets their needs. And that means, in most cases, the availability of a vaccine and reduced infection rates in their local communities.

So I do think if you look at most of the forecast and the forecast that we believe internally, we think that means patients begin returning to elective care, not just SCS, but returning to these types of elective procedures in second quarter and that the pace really begins to pick up in Q3 and Q4.

Now that's based on a lot of macro assumptions about how things play out with a worldwide pandemic. So we don't have any particular or unique expertise on that topic. We're following it as closely as we can and as closely as most, but that's sort of our view of things right now..

That's good color. And as my follow-up, you also provided a lot of good color on your PDN strategy.

As you start looking at the data, it's been a month since NANS, what kind of has been the data point that has surprised you the most? And kind of makes the argument even more compelling potentially?.

I'm sorry, the data point that has surprised us the most in the clinical trial data?.

Yes..

Yes, I think there's two things that that have really been received well by the clinical community. One is the sustainability of the pain relief. So if you look at what was really dramatic payment relief at the 3-month point, I think the big question that it raised among most was, hey, look, this is great.

But it's 3 months, can we really sustain pain relief this dramatic at 6 and 12 months? So I think what has gotten a lot of discussion, a lot of attention and it will be reported on in future publications is the rate at which we've been able to keep pain relief in these patients over time.

And I think that's what patients were referring doctors and importantly, what payers will want to see. We continue to see sensory restoration in these patients at 6 and 12 months. We continue to see quality of life improvements in these patients. We know that those are going to be important to payers and the referring doctors in our research.

And so I think just the ability to sustain some of these things that were so dramatic at 3 months, out to 6 and 12 months, particularly in those areas, are the things that have been received particularly well..

Your next question comes from the line of Bill Plovanic with Canaccord Genuity..

First, I'm just curious with -- obviously, we're seeing an impact on procedures. But I -- we're listening to other companies report their quarters and some have done a little better, some a little worse.

And I'm just -- what -- I'm trying to understand, what gives you confidence that it truly is a center patient issue and not a share loss issue as we come into the fourth quarter and into January? And then I have a follow-on..

Yes. Well, we track the market. I mean we do it internally, and we use third parties, and we're very confident that it's not a market share as you're, in fact, quite the opposite. We've picked up share we think in every quarter of 2020 and throughout most of 2019. So I don't think this is a share issue. This is a -- in fact, I'm certain of that.

This is a market issue. And as we dissect all the things that might make up a market issue, it really comes down to patient behavior. And it's patient behavior relative to pandemic infection rates and vaccine availability. I mean it's a relatively complicated landscape.

But if you really tease through the unimportant to get to the importance, that's what this is about..

Great. And then on the PDN watch, I think you've given a lot of color about kind of the timing of the costs and the general buckets of the cost.

But I'm trying to understand, as you spend on this launch, how much of these expenses are onetime in nature, building all the materials, building all the programs, what have you, maybe starting some of that direct-to-patient versus ongoing in nature?.

Yes. I think there's some substantial portion of each. I mean on the other hand, project-related program design, consulting, building out of initiatives those are onetime expenses in the year. That doesn't mean you won't have other similar expenses in the following year.

So it's kind of difficult for me to say that, hey, of this invested amount this year, you can expect x percent to be repeated in the following year. But I will say this is probably a particularly intensive year from an investment standpoint because we want to launch this right.

We think this is a uniquely good opportunity for the company, and we want to get it right the first time..

Okay. And clarification on Costa Rica, will Costa Rica be up in shipping product this year? Or is that a 2022 event? That's all..

Yes. Yes, Bill, that's a '22 event. So we assume that we're FDA-approved and shipping commercial product sometime in '22..

Your next question comes from the line of Bob Hopkins with Bank of America..

Keith, I appreciate your quantification of the potential backlog of $500 million to the industry. And I guess, given your share that's maybe right to win and maybe $100 million of that or more.

I realize there's some pretty simple math, but I'm curious how you went about thinking about the guidance that you just provided us for 2021 as it relates to that backlog, right? Can you share any thoughts on how much of that backlog you assumed you would capture in the year versus sort of normal trend growth? And just kind of curious how you went about constructing the guidance relative to the backlog..

Well, of course, we don't start with guidance. We start with an internal plan. And in that internal plan, we don't really assume because there's no way for us to assume that demand for the therapy that seemed to vanish in 2020 over 2019 comes back at a certain pace or a certain share of that because there's just no way to really know that.

Now the part of the uncaptured demand that we can quantify are patients that we know were in the funnel. And we've talked about those a lot. So canceled cases, deferred trials, canceled trials, canceled perms, we track them all pretty thoroughly and carefully internally.

Those we can be relatively certain when they're going to come back, how many will come back in 2021. We can't always pinpoint the month or even the quarter. But we have a pretty good idea of what contribution that plays in this year's plan. And of course, we haven't broken those things out.

But in terms of the guidance, there's a lot of uncertainty around some of the things that we've been talking about. And we felt it was important to give guidance. We've had guidance withdrawn for the last year.

There was a fair amount of complexity that we wanted to be able to communicate to you this year around PDN spend, revenue contribution, timing and cadence, et cetera. And felt it would be difficult to do that without giving some guidance. However, it's a pretty fuzzy environment right now.

The implication there for guidance is that you're probably going to err towards a larger range and you're probably going to err towards some measure of conservatism. And that's, in fact, where we've ended up.

But to say what wasn't part of our calculus, Bob, was to say, hey, there's $500 million of market in 2019 that just wasn't there in 2020, even though we know the patients were there. Therefore, we're going to get 20% of that, and it's going to happen over the next 22.5 months.

It's not that precise, and it's frankly not reflected in our guidance or even in our internal projections..

Yes, that sounds logical. I appreciate that. The other question I wanted to ask is just it's a little bit more of a 2021 question, and I realize there's a lot of legitimate excitement about what you guys could do towards the end of the year and into 2022 and beyond.

But coming off NANS, there's a lot of competitors talking about a lot of new waveforms, new technologies. And just curious, as you're out in the marketplace recently because a lot of these things are brand new. Your thoughts on the competitive landscape as we look to the next 12 months here before you've got these new indications really kicking in.

Just are you seeing anything different on that front relative to all the noise that we heard at NANS?.

No. I mean there's really not much significant that's new. I mean I think the newest thing probably was Medtronic's introduction of the DTM waveform. There's really not that much else out there that's new, that's really meaningful or that different. Now there are some things coming. We've talked about the Saluda introduction, the Biotronic introduction.

We are hearing late this year or first half of 2022 in both cases. But really, none of that is new that we've been talking about those things for the last couple of quarters. So I don't know that we see the competitive landscape that differently than we did before..

Your next question comes from the line of Larry Biegelsen with Wells Fargo..

This is Kevin [ph] on for Larry this evening. I wanted to follow-up on Bob's question around the guidance. And I completely understand it's very difficult to forecast. I guess I was curious, with 10% to 15% growth over '19, do you have a sense for kind of the assumptions you used around U.S.

SCS market growth in the number? And I appreciate that the funnel is difficult to understand.

But kind of if you assume the similar percentage came back of canceled cases and the bolus that you saw in Q3, how does that factor into the numbers? And then I was curious kind of as you think of the low and the high end of the range, is it fair to say that the 10% is a floor based on what you see today with no additional wave of COVID and increased vaccine adoption?.

Yes. I mean I think from a guidance standpoint, it's -- the guidance kind of stands on its own. I mean we -- that's the low end of the range, so we would consider that a floor. Look, I could sit here. And in this kind of environment, I could easily color a case of downside below our guidance and upside above our guidance.

So -- but our guidance attempts to contemplate at the lower end, what we would consider to be a floor -- a reasonable floor of performance. In terms of the growth of the market, we've decided that we don't want to be the oracle of market growth here at Nevro a couple of years ago. And so haven't weighed in on that very much.

But if you look at the growth over -- you phrased it versus 2019, but I think our -- the range of our guidance over 2020 is something like 16% to 24%..

19% to 24%..

19% to 24%. Our assumptions are that at 19% to 24% from min to max on our guidance range, that we continue to gain some market share this year. So it's safe to assume that our assumptions about market growth are lower than the assumptions that we are giving you for our growth rate..

Your next question comes from the line of David Lewis with Morgan Stanley..

Just two quick ones for me. I guess, one, just back on the first quarter guidance. I was just sort of taking a look at seasonality. The seasonality you're looking for in the first quarter is basically dead in line with the seasonality we've seen in the last 2 or 3 years or the last 2.

And I'm just trying to figure out, does that make sense that seasonality would be traditional heading into the first quarter relative to last couple of years, it seems like that would not be the case. And then I had a quick follow-up..

I would say there's nothing about normal quarter-to-quarter seasonality that is factored into our first quarter guidance. In this environment, I don't know how much that would matter. We're sitting here further than midway through the quarter. We've got a fair amount of exposure to the quarter and what's happening with our patients and our centers.

And it has everything to do with where we actually think the quarter is going to be. In other words, for me, as I think about first quarter, seasonality relative to Q4 would be an output, not an input, to my thinking.

David, I assume you're saying it under normal course, it should be higher or lower in your view?.

Well, it should be -- the point is I think you kind of answered the question, which is that it may just be happenstance that it comes out that way because in this particular quarter, I can't think of anything that's normal. It doesn't sound like you relied on historical seasonality gets for the quarter.

It sounds like you did a bottoms-up and the numbers landed where they landed..

That's exactly right..

Okay. And then, Keith, just related to that, and I'll ask both my little questions here. First, you typically have a trial to perm ratio that's pretty predictive.

Did you assume that predictive trial to perm ratio and then the back half of the 6 weeks of the quarter or did you assume a more conservative number? And then I'll ask my second question just right now which is on PDN. Keith, it's hard to note that $22 million, what's reps, what's not, but that could be 50 reps.

Is that kind of in the ballpark for your referral force? And where does that referrals have to be in terms of total rep count to win here over the next several years?.

Okay. Yes, on the forecast, there's a lot of ways we triangulate to a forecast internally. Only one of those tools is the model using trial-to-perm conversion rates. So now we might rely on it a little further as we look at, say, an annual number, but for a quarter or halfway through, it's only part of the it's only part of the calculus.

We actually have patients already on the surgical calendar, et cetera. So that's kind of how we think about the forecast halfway through a quarter. It is an input, but it's not the only thing we're relying on. On the spend estimate for PDN, that includes -- you're not too far off, David.

That includes a field headcount of between 30 and 40 folks that will be in a separate detailed organization, which is a referral organization.

They won't have anything to do with procedures, with surgical procedures, with patient programming, there'll be detailed reps that will be out talking to those highest volume, referring doctors and detailing data et cetera. And it's -- that's about the size of that initiative for this year..

Your next question comes from the line of Robbie Marcus with JPMorgan..

This is actually Allen on for Robbie.

So when we think about PDN and kind of the gating factors to the launch, the pace of getting coverage, educating physicians, how should we really think about that playing out over the course of 2021 and into 2022? You highlighted and expecting to have like a pretty good funnel heading into 2022, but how should we really think about that building up?.

I want to make sure I understand the question, Allen. So you're -- are you asking how we're thinking about kind of the calculus between the number of patients referred or trialed in '21 versus expectations for '22 with PDN? Or maybe you could be a little bit more specific..

I guess some of the gating factors behind, actually, getting the new referring organization to these docks. And then obviously, it's not exactly to get then those patients into the right place.

So how should we think about the kind of delay and lag to actually getting patients onto an SCS system?.

I see. Well, I mean, if you look at the numbers that we've talked about today, it assumes there's a definite delay. We don't want anyone's expectation to be the day we announced we have FDA approval that we're starting to put implants in people. We've got to go out and educate something that we can't do on label until we have that FDA approval.

That education has to show up in the form of referred patients who then have to move on to trials and then perm. So it's a treatment pathway that takes a little bit of time. Thus, our guidance.

So you should be thinking about -- I would say, look, our research suggests that both patients and referring doctors are extremely receptive to this data, the ones who have seen it. Most haven't yet seen it. So we've got to get out to the ones managing most patients, educate them and begin to get that referral stream started.

I think it will be -- I think we'll be pleased with the activity. That's just my opinion. I think based on the research we've done, we're going to see the referral stream pick up relatively quickly. We don't have any experience yet with the rate at which those referred patients convert to trials and then perms.

What I want is to come into '22 with a lot of patients having been referred and beginning at the very least to enter the trial part of that algorithm..

Got it. And then as a quick follow-up. So CMS finalized the decision to essentially mandate authorization for SCS patients. You've highlighted in the past how this isn't exactly as relevant for your business and how you view this as more of an issue for primary cell devices rather than rechargeable.

But how should we really think about the impact of that going forwards, both for yourself and the broader SCS market?.

Yes. Actually, this is for any SCS procedure. It's -- and it's for Medicare fee-for-service patients in the hospital setting. So that all kind of whittles down what I said if you take each step, it whittles down to something like a mid-teens, I think, percentage of our patients. But it's not necessarily just primary cell devices.

It's all SCS devices that fall into that category. That comes into effect midyear, I think, July 1. And frankly, that will put that patient group kind of in line with most of the patients we treat that already go through a prior auth procedure.

So it's not both the percentage and the conformity with the rest of our patients make it a change that we're not terribly worried about. We don't -- we prefer it not happen, but we're not terribly worried about it from a business standpoint..

Your next question comes from the line of Danielle Antalffy from SVB Leerink..

Keith, I wanted to ask a kind of higher-level question. I hope it hasn't been asked. I apologize, lots of balls in here right now. But just as we look at -- so Nevro came out initially with the first sort of randomized clinical trial, that demonstrated a meaningful benefit versus an existing device.

Now you've got the PDN data, you've got the nonsurgical refractory back pain data. I mean, at some point, it feels like this data is just continuing to validate the efficacy of the device. I guess my question is, how has the conversation with physicians -- and specifically, those that have been maybe like late adopters or downers about the technology.

How has the recent data changed that conversation? And then the second part of the question I'll ask now is when you look at aspirational market shares in this market, given the fact that you do have all of the data, what should we be thinking about with where Nevro would stack up within the core players?.

Yes. Well, I think every little bit helps. I think the combination of the original RCT data that we brought to the market initially with high-frequency SCS combined with countless smaller data sets along the way and then the addition of these 2 larger RCT data sets in NSRBP and PDN. They all add to the story.

They all make a difference, and I think they all make us a more attractive option for doctors and patients. I think the proof is in the pudding. It's in utilization. I think what we've seen over the course of 2019 and 2020 is the best reflection of whether or not it matters. We think it does matter, along with other things.

But we think the gains and market share that we've made of late on the back of many of these data sets is the best way to answer your question. I think that will continue to be the case. And I think we'll enjoy the PDN market really, if not completely to ourselves, I think we'll enjoy the lion's share of that market for some time to come.

And so I think if you consider PDN as part of the overall SCS market, I think that, of course, all by itself will help grow our market share.

But if you look at just lower back and leg pain market as it exists today -- market share -- by the way, let me preface it by disclaiming that market share is really tough to put your finger on in this market for lots of reasons that most of you know. And so I won't bore you with them. But it is rather opaque.

Having said that, we think ending 2020 on a dollar basis in the U.S., we are about a 20% - 21% percent market share participant. The leader in this market is probably in the low 30s. So market share is spread not evenly, but somewhat evenly over 4 participants.

I think, look, the challenge to our organization is that over the next 5 years, we want to be a leader in this market. We think we can be and in fact, we think we should be a leader in this market. What that means in terms of market share, that will change over time. We'll have more market participants. Market growth could vary over that time frame.

Do you include PDN or not if we're the only ones participating? But I think we deserve to think of ourselves as a market-leading technology in this business over the coming years. And I think that's certainly our aspiration and expectation for this business..

Your next question comes from the line of Kaila Krum with Truist Securities..

Just a couple on PDN for us. So first, you guys said you may have about 1/4 of the market covered by payers at the time of launch.

I mean, how quickly do you think other payers will follow? And is it a function of needing more data for those other payers? Or is it a function of timing of policy updates, which just generally happen in January and the summer?.

It's both. It is both. It's -- keep in mind, some of these payers, we just -- they haven't even had the conversation yet. Some of these payers may not even be aware of the data yet. So we're in the process of implementing a plan that will put us in front of all these payers with the data so that they can make sensible decisions.

I mean most of their non-coverage policies that are in place or in place simply because there wasn't a reason to have a coverage policy. They didn't have data. They didn't have explicit approval for this etiology.

And so it's not that they had an inherent bias against treating these patients with this technology, they just didn't have anyone approved who had RCT data. So I think our progress will be good, Kaila.

It's really hard for us to quantify to we think we can get from this percent to this percent over the course of 1-year cycle because this is the first time going through this with this indication, this data and these payers.

So I'm really reticent to give you any predictions other than I think of the interactions we've had so far, we're encouraged by the reception to the data that we've had..

That makes sense. And then just if PDN contributes $5 million to $6 million in the fourth quarter, I mean, annualized, that's $20 million to $25 million.

So I guess, would you consider that sort of the floor for what PDN could represent in 2022? Or what in your view would push that number higher or lower?.

Yes. Look, I mean, I wouldn't expect -- I don't want to guide for '22. I don't want to give multiyear PDN guidance. But I certainly would expect Q4 to not be high for some reason. In other words, if we were to use your #5 or 6 in Q4, I guess everyone around this table would be a bit surprised if 22 was a simple 4x of that number.

I would expect -- and you can, I think, judge by the way we're investing in it this year, I would expect '22 PDN revenues to be some interesting multiple, whatever we're able to turn in, in this year's performance. And 4x Q4 would seem to be a reasonable way to think about a floor, yes..

Your next question comes from the line of Matt Taylor with UBS..

This is Young Li in for Matt. I guess on the international launch plans for PDN, can you maybe just help us think about the market sizing and opportunities in the 3 countries you mentioned relative to the U.S.

and then maybe if you can talk a little bit about the pathway for other countries to come online in the coming years?.

Yes, I think we actually spoke to that in our prepared remarks. We're going to be rolling out our PDN marketing initiatives in most of our markets. In about the same time frame, we're rolling them out in the U.S. So the second half of the year. I'm not prepared today with total PDN populations in those markets.

That's something we might be able to speak to in future calls. But certainly, there's significant interest in our Australian and European markets. And in some isolated pockets, they -- they're beginning to look at patients for PDN now where they have -- where they believe they have approval.

But we don't expect to put a lot of our own initiatives in place until the second half of this year when we're launching more broadly. So I would say maybe more to come on some of the market sizes for the OUS markets in the next couple of quarters..

Okay, great. That's helpful. And then I guess, maybe just one on longer-term margins. I remember last year at NANS, the in-person one, you talked about guiding to positive EBITDA. And a year later now, you're guiding to similar levels in terms of revenue and EBITDA. A lot's happened over the past year.

So I was just wondering, in your view, in terms of the longer-term margin potential for Nevro, how has your view changed compared to your thinking about a year ago?.

Yes. Well, in the short term, of course, has been -- it's a completely different picture now than it was at prior year's NANS, which was before anybody was thinking about COVID. I don't think the longer-term view has changed.

As we think about a business like ours that is in the roughly 70% gross margin range, we think, obviously, as Rod mentioned a moment ago with our own manufacturing, we think the gross margin profile can be better than that over time.

We think there's lots of ways that we've already articulated that we'll see efficiency in our cost of growth going forward, and particularly in our commercial costs.

I would say, look, if you look across the Medtech landscape, at scale, and let's say, scale is 500 million to 1.5 billion companies that are in that range for gross margin are typically in the 20% to 30% operating income range and probably are closer to 30% than 20%.

I think at those kind of scales, we wouldn't have a different expectation for this business. So I think we feel as though this business scales very attractively over the next $500 million in revenue..

Your next question comes from the line of Margaret Kaczor with William Blair..

This is Maggie [ph] on for Margaret. So you launched Omnia about a year ago now and maybe didn't get as much uptake as you would have thought because of COVID.

What's your penetration in your accounts of Omnia today look like? How do you expand the penetration into other accounts going forward? And how impactful do you think the recently approved new updates can be an expansion in revenue growth?.

Yes. I think in the U.S. market, Omnia is up to, last time I looked around, 74% of -- 74%, maybe 75% of all utilization. So it's received pretty widespread adoption among our users.

Of those 5 market share points that we think we've gained over the last 2 business cycles, we think somewhere between 1.5 and 3 of those points came in 2020 since we launched Omnia despite the COVID environment. And we think omni had a lot to do with that.

I think part of the value proposition that we laid out for our customers with Omnia when we launched it was the promise that we would be able to make improvements, make changes, they wouldn't have to think about reimplanting patients are only getting access to those improvements in new patients that we would be able to upgrade the existing Omnia.

And less than a year later, we're already talking to them -- or about a year later, we're already talking to them about a major upgrade that's responsive to, in many cases, their needs. So I think Omnia will continue to allow us to get traction.

I've said this before, it's not a typical product innovation cycle in the sense that it really was a major strategic shift for us. It was going from just high frequency to offering high frequency uniquely as well as every other frequency available.

And I think that's sort of part of the value proposition that's not -- that others can't replicate and that's pretty enduring. So we think for all those reasons, we're able to continue to use Omnia to capture share for some time to come.

And as we think about Omnia's impact, I mean, it's an important part of some of the growth expectations we've talked about today..

Great. That's helpful. And just for my follow-up, looking 3 to 5 years out, what do you think the market will look like from a growth perspective and a penetration perspective? What do you think the next evolution of the market will be? So the past couple of years, we've seen different focuses on waveforms, indications and various device sizes.

So what is never specifically going to be putting their investment dollars behind to spur future growth outside of new indication?.

Yes, well, I'm not going to predict the market size 5 years out. I think it's going to be one of those markets that, given the size of the underlying TAM, just continues to offer year-over-year growth rates.

I don't think it's a market that all of a sudden, based on any innovation -- just because it's a large addressable market, all of a sudden grows 30% or 50% just because the patients happen to be there.

But I do think it's a market that because those patients are there, grows at an attractive rate as technology gets better and awareness of the technology and the outcomes becomes higher over time. And that's one of the things we like about the underlying markets as we think that they offer that kind of growth that we can build on.

What drives that kind of growth in terms of innovation? Look, I think there's a lot of interesting things coming.

If I think about some of the things that we think will drive that kind of growth, it's innovation in the areas of both frequency and wave forms of innovative form factors of the use of big data and AI to inform therapy choice and improve outcomes. It's data to treat new patients and new categories of patients, like we've seen in PDN.

I think there's a lot of things that are capable of growing this market and all of those areas I just listed are areas in which we're making investments..

Your last question comes from the line of Suraj Kalia with Oppenheimer..

So Keith, you gave a lot of commentary on PDN, and I know a number of questions have been asked. Let me ask the same thing a little differently, Keith.

Can you give us a specific example of medical device surgical reps in the PCP and endocrinology suite that could possibly guide us our thought process on the PDN market development? Any other device that you all are modeling or thinking through, here are the reps, they were surgical reps in a PCP endocrinology suite making an argument to have patients jump over into surgery..

I'd have to think about it. I'm not going to give you off the cuff, but I mean people have employed referral sales organizations to call on the PCP market to refer patients for years. It's certainly in the pharma space, but in the [indiscernible] space as well. I don't want to just come up with one off the cuff.

Suraj, maybe you have one in mind, and that's why you're asking. But something we can think about and happy to talk to you about that later..

Got it. And Keith, one last question, I'll hop back into the queue. You've been there at the helm for two years.

Keith, as you look at the market, from a bird's eye view perspective, what is your impression of switching costs in the market? Just trying to piggyback on Bob's earlier questions in terms of the number of wave forms, that is obviously a new entrant that is going to be coming into the market and the field checks do come back positive.

And I'm curious how you see the switching cost from one platform to another, as you've spent over the last two years..

Well, look, I mean, switching costs, as I compare them to other segments of Medtech, I suppose, are reasonably low. I mean one doesn't have to invest $1 million in capital equipment and training and refurbish in a war suite and that kind of thing to employ the use of a different implantable as we see in other segments.

So if you're a doctor using one SCS system, the costs necessary to be trained and deploy another system, I would say, in my experience, relative to other sectors is relatively low.

And I think that's to both our advantage and disadvantage, right? I think we've been capturing share and some of that has come in competitive accounts or splitter accounts, and it's -- and we benefit from that very fact.

Maybe you can expand on your question, Suraj, and tell me what you're actually trying to get to?.

No, Keith, no subliminal question. Just trying to understand, one of the key things is just in the overall space, right, wrong or indifferent, the lack of head-to-head studies -- questions about durability, x plan and so on and so forth, everyone has a certain argument. And there is obviously a new entrant that is going to be coming in shortly.

So just trying to wrap around our head, what should we see possibly in terms of share shifts and how you all think through that? That was really the gist of the question..

Yes. I think, look, any credible new competitor that does it right, that has the resources and has good data and has a good system, has the expectation of coming in and getting some share.

I'm not going to sit here and predict which entrant might get what amount of share from which entrenched competitors or existing competitors because I don't know that. If you look on one case is Nuvectra, where there was a lot of valuation and high hopes about the share that, that device would take, and that didn't happen.

There have been some other smaller devices that have come into the market, I think, with the intent of taking more market share and they haven't. This is not an easy market to come in and enter. I mean it requires more than a good technology, more than good data and more than innovation.

There's a significant market footprint that has to be -- an a credible one, that has to be built for customers to begin to rely on you as a technology provider. And it's not inconsequential. And there are tough competitors in this market, and we consider ourselves one of them.

So I think for someone new coming into this market, they've got to do a lot other than just bring new innovation. Now if they do those things, then you've got to look at the innovation and say, who is most likely to want to use that, which doctors who use which devices now in which patients.

And the vulnerability to a new entrant is not going to be the same on the part of every competitor in the space, and those are things we consider as well. I think we feel like we're pretty well positioned..

And there are no further questions at this time. I'd now like to turn the conference back to Mr. Keith Grossman for closing remarks..

Okay. Thank you, everyone, for joining us. We appreciate it. We look forward to talking to you next quarter and giving you an update on our progress..

Ladies and gentlemen, this concludes today's conference call. We thank you for your participation. You may now disconnect..