NVRO

Operator: Good afternoon. My name is Audra, and I will be your conference operator today. At this time, I would like to welcome everyone to the Nevro Corp. First Quarter 2024 Earnings Conference Call and Webcast. Today's conference is being recorded. [Operator Instructions]

At this time, I would like to turn the conference over to Angie McCabe, Vice President, Investor Relations and Corporate Communications. Please go ahead.

Angeline McCabe: Thank you, Audra. Good afternoon, and welcome to Nevro's First Quarter 2024 Earnings Conference Call. With me today are Kevin Thornal, our CEO and President; and Rod MacLeod, our Chief Financial Officer.

Before we get started, please note that our earnings release and the supplemental presentation accompanying this call are available on the Events & Presentation page of the Investors section of our website at nevro.com. Also, this call is being broadcast live over the Internet to all interested parties, and an archived copy of this webcast will be available in the Investors section of our corporate website shortly after the conclusion of this call.

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. Results could differ materially from those expressed or implied as a result of certain risks and uncertainties. Please refer to Nevro's SEC filings, including our annual report on Form 10-K for detailed presentations of risk. The forward-looking statements in this call speak only as of today, and the company undertakes no obligation to update or revise any of these statements.

In addition, management will refer to adjusted EBITDA, a non-GAAP measure used to help investors understand Nevro's ongoing business performance. Adjusted EBITDA excludes interest, taxes, noncash items, such as stock-based compensation, depreciation and amortization, litigation-related expenses and credits, changes in the fair market value of warrants and other adjustments such as gain from extinguishment of debt and restructuring charges. Please refer to the financial tables in our earnings press release issued today for reconciliations of GAAP to non-GAAP financial measures.

I will now turn the call over to Kevin. Kevin?

Kevin Thornal: Thanks, Angie. Good afternoon, everyone, and welcome to our first quarter 2024 earnings call. A short time ago, we reported our first quarter results with revenue and adjusted EBITDA exceeding the guidance we provided on our fourth quarter 2023 earnings call in February. We also announced we are taking additional restructuring steps to further advance our strategy and accelerate our path to profitability, reaffirming our full year 2024 revenue guidance, raising our 2024 adjusted EBITDA guidance to a range of negative $5 million to positive $2 million and providing our second quarter 2024 guidance.

In addition, I'm thrilled to announce that Chris Christoforou, has been promoted to Chief Operating Officer. On today's call, I'll discuss the progress we are making in advancing our 3-pillar strategy, including highlights from the first quarter and the additional restructuring actions. Rod will then discuss our first quarter financial results and provide more detail on our guidance for the second quarter and full year of 2024.

In the first quarter, we continued to advance our 3-pillar strategy of commercial execution, market penetration and profit progress, and this is reflected in our overall results. For the first quarter of this year and as compared to the year ago period, worldwide revenue was $101.9 million, an increase of 5.8% on a reported basis and 5.6% on a constant currency basis. This year-over-year growth was largely driven by a product mix shift to our newest generation SCS platform, HFX iQ, as well as an increased number of long-term Nevro patients who are now suitable candidates for replacement device.

As a reminder, our devices have rechargeable batteries with a very long functional life. But even in this case, we believe these devices eventually require replacement. Our earliest patients are now out about 10 years or more. We believe many of our patients will want to continue accessing our unique and successful high-frequency therapy through a newer Nevro device. While this is currently a small part of our SCS business, we believe it may play a slightly larger role in our implant volumes over time.

U.S. trials were down approximately 5.1% compared with the year ago period. This was largely in line with our expectations and mainly driven by 2 factors: first, softness in overall U.S. SCS trialing activity in the quarter; and second, the impact of interest among ex-SCS customers in attending our SI joint fusion training sessions which take physicians out of the practice for a day or 2. In fact, we added more training sessions in the quarter to accommodate physician demand to learn this procedure. We are conducting additional SI joint training sessions throughout the second quarter and the remainder of the year.

From a cadence perspective, and Rod will discuss our guidance in a few minutes, revenue in the first half of this year is on track with our expectations. This, combined with several factors such as: one, our continued focus on growing our business by selling our superior therapy to competitive physicians; two, growing the market through our expanded indications such as PDN, which continued to show solid growth in the quarter; three, beginning to realize early results as our SI joint business gains traction in the second half of this year; and four, leveraging our SI joint business to sell more SCS devices into competitive accounts, gives us confidence that we can achieve our full year revenue guidance of $435 million to $445 million.

We also reported a net loss from operations of approximately $35.8 million and adjusted EBITDA of negative $9.6 million. As it relates to the first pillar of our strategy, commercial execution, in the first quarter, sales reps who joined Nevro in the second half of last year continue to ramp up on the business, and we commenced the limited market release of our SI joint products. We also continue to focus on educating our customers on the benefits of our superior SCS therapy.

We are driving the increased adoption of HFX iQ, our newest generation SCS system that brings a multitude of benefits to the patient and physician. HFX iQ represented 58% of our total permanent implants in the first quarter, a 5% increase from the fourth quarter of 2023. To broaden access to this therapy for more patients, in mid-April, we launched a solution for nearly half of the patients who do not have a compatible iPhone, including those with an alternative smartphone device.

As we previously communicated, our real-world data shows that our HFX iQ system in combination with the cellphone app helps patients get back to pain relief faster than those who use a traditional remote by allowing the patients to have more input on and control over their therapy. We expect continued HFX iQ adoption as we educate the market on the benefits of this therapy.

We also continue to advance the second strategic pillar of market penetration, where we focus -- where our focus is on expanding into new indications, developing and launching enhancements to our HFX iQ system, executing on our robust R&D pipeline and, as appropriate, targeting additive acquisitions to drive profitable growth. In the first quarter, we focused on integrating our newly acquired SI joint fusion business and, as I just mentioned, commenced the limited market release of our SI joint products and prepared for the broader release of our SI joint products to the market throughout the remainder of this year.

By expanding our product portfolio to include solutions for SI joint pain, we are now engaging with physicians who have not previously utilized our products to now offer treatment options for patients with different chronic pain conditions. Notably, we believe that 15% to 30% of low back pain is caused by SI joint dysfunction. In the U.S., approximately 1.9 million patients receive an SI joint diagnosis annually, representing a $2 billion market opportunity. Through this expansion in therapeutic options for pain patients, we are now able to address more patient needs and leverage our SI joint solutions into business at competitive SCS accounts where we previously did not have access.

During the quarter, we conducted several SI joint vision training sessions for physicians and our sales reps with a primary focus on Nevro1, a stand-alone device with integrated transfixing technology that has proven to immediately transfix an SI joint to allow the opportunity for long-term fusion. Year-to-date, more than 220 physicians participated in our SI joint training sessions. Many of them are current customers who took the time to learn a new SI joint fusion procedure so they can utilize our innovative products to treat their patients suffering from chronic pain.

Early feedback from physicians who attended our training sessions has been very positive, and they believe Nevro1 is an excellent treatment option for patients suffering for SI joint pain. We continue to see significant physician interest and demand for training on our SI joint products, particularly Nevro1.

As we roll out our SI joint products across the market, many of the physicians that we trained are identifying patients in the practice who suffer from mechanical back pain that could benefit from an SI joint fusion procedure. Importantly, we continue to train our sales force and are leveraging our commercial team to drive adoption and growth. Also, as adoption of our SI joint products increases, we will gain greater access to physicians who might be interested in using our SCS products to treat their patients, as many physicians should perform SI joint fusion procedures also implant SCS devices.

We are also thrilled that in February, the Food and Drug Administration granted 510(k) clearance for Nevro1 without the need to include the NevroFix group. This marks the first regulatory clearance since we acquired Vyrsa late last year. Nevro1 as a stand-alone device represents a significant advancement in SI joint fusion and we believe it is the most efficient, effective and safest SI joint fusion implant currently available on the market.

As a health care company with a vision to free patients from the burden of chronic pain, we remain focused on increasing awareness of SCS as a treatment therapy for painful diabetic neuropathy, or PDN, and other indications. At just under 1%, the PDN market remained significantly underpenetrated, and we are working to develop this market with our innovative technology and superior clinical data.

Diabetes is a major global public health concern and continues to grow in prevalence. It can lead to a variety of complications, including nerve damage, reduced circulation, diabetic ulcers and limb loss. In the first quarter, 24 months data from our SENZA-PDN RCT demonstrate improvement in sensory function that can lower the risk of diabetes-related ulcerations and traumatic amputations for patients suffering from severe side effects in diabetes was published in the Journal of Diabetes Science and Technology.

We continue to be a leader in developing superior clinical data showing the efficacy of our best-in-class 10-kilohertz technology. As we've discussed on prior earnings calls, our PDN clinical sensory study is designed to more objectively prove the sensory improvements that we observed in our initial randomized controlled trial, or RCT, and to obtain an SCS indication beyond just pain. We're pleased to share that enrollment in the outstands at 140 patients ahead of our plan.

As a result, this robust enrollment and the strong outcomes demonstrated in our SENZA-RCT, we are pausing enrollment in the PDN sensory study to allow for an interim primary endpoint analysis of all subjects who are randomized from this existing cohort. While the results of the analysis may indicate restarting enrollment in the future, our goal is to bring trial results to publication as soon as possible for the benefit of patients and review for inclusion in therapeutic guidelines.

The third pillar of our strategy is profit progress. We remain focused on executing key initiatives to become more efficient, scaling our Costa Rica manufacturing facility and maintaining disciplined expense management to expand margin and achieve profitable growth. We made good progress on this front in the first quarter as demonstrated by adjusted EBITDA coming in ahead of our expectations. We are taking additional restructuring steps to make Nevro a stronger, healthier and nimbler company so that we can advance our 3-pillar strategy and accelerate our path to profitability.

We are laser-focused on managing our expenses and aligning our cost structure with our business, and have identified areas and key initiatives that we believe will drive growth and profitability. We continue to invest in our R&D pipeline to develop and commercialize innovative treatment therapies for patients suffering from chronic pain. Rod will discuss our full year guidance in more detail, but as a result of our first quarter performance, additional restructuring steps and outlook for the remainder of this year, we are raising our adjusted EBITDA guidance to a range of negative $5 million to positive $2 million.

As part of these steps, I'm thrilled to announce that this Chris Christoforou has been promoted to the newly created role of Chief Operating Officer. In addition to his current responsibilities leading our manufacturing processes and research, development and innovation efforts, as well as spearheading the integration of Vyrsa into our operations, Chris will now have oversight of clinical and regulatory affairs and quality assurance.

Chris has been with Nevro for 8 years, and during this time, he has proven to be a valuable member of our team. His strong leadership skills, technological experience and deep knowledge of the med tech industry make him the right choice to serve in this role. We continue to transition more of our manufacturing to our Costa Rica facility, and as we sell down inventory that is produced by our second source supplier and manufacture more in Costa Rica, we expect to see increased margin expansion over time. We will also leverage our Costa Rica facility, which is supported by best-in-class manufacturing experts and technology, as we grow our business through new products we develop as well as tuck-in acquisitions.

In summary, over the past year since I joined Nevro as CEO, we've made significant progress in advancing our 3-pillar strategy to further position our company for the opportunities ahead of us. We're excited about our future as we have multiple growth drivers in the SCS market, including through expanded indications as well as the SI joint fusion market.

We entered the fast-growing SI joint fusion market through our acquisition of Vyrsa and are focused on ramping up that business. We will continue to differentiate ourselves through our unique 10-kilohertz technology that produces superior outcomes, and we will continue to capitalize on meaningful leverage opportunities to drive long-term profitability, generate positive cash flow and deliver shareholder value.

I will now turn the call over to Rod for a discussion of our first quarter financial results and 2024 second quarter and full year guidance.

Roderick MacLeod: Thanks, Kevin, and good afternoon, everyone. To echo Kevin's remarks, we are pleased with our first quarter 2024 performance as we made further progress on advancing our 3-pillar strategy. For the first quarter of 2024, as compared with the year ago period, worldwide revenue grew to $101.9 million, an increase of 5.8% as reported and 5.6% on a constant currency basis, and was primarily driven by a mix shift to higher-priced products as well as the growing number of patients who are now suitable candidates for a replacement device, as Kevin discussed earlier. Also, there were 64 selling days in both the first quarter of this year and last year.

U.S. revenue grew 5.7% to $87 million. International revenue was $14.9 million, increasing 6.1% as reported or 4.7% on a constant currency basis. Gross profit increased 10.7% to $71.5 million, and gross margin increased 310 basis points to 70.2%, driven primarily by a shift to higher margin products that are manufactured in our Costa Rica facility.

Operating expenses increased to $107.4 million compared with $100.9 million in the prior year period and included the impact of the following items: first, a $5.5 million charge related to our January 2024 restructuring; and second, 2 Vyrsa acquisition-related items comprised of a $3.5 million charge related to the change in fair value of the contingent consideration liability as well as $700,000 of intangibles amortization. Excluding these items, operating expenses decreased approximately 3.3% versus the prior year quarter, reflecting our ongoing focus on disciplined expense management and driving operational efficiencies throughout the organization.

Litigation-related legal expenses were $2.8 million compared with $3.8 million in the first quarter of 2023. We are pleased with the recent ruling in our favor in our arbitration against the Mayo Clinic and Flathead Partners. We now consider the matter concluded with no finding of liability against Nevro.

Cash, cash equivalents and short-term investments were $281.5 million at March 31, 2024, a decrease of $41.2 million from December 31, 2023. This decrease was primarily due to customarily higher cash outflows that occur in the first quarter, a $9.8 million Vyrsa related milestone payment made in the quarter related to the FDA 510(k) clearance that Kevin discussed earlier, and that was achieved sooner than we anticipated, and $4.4 million in restructuring-related payments.

As Kevin discussed in his remarks, in the first quarter, we focused on training physicians and the salespeople who support them in performing SI joint procedures using our portfolio of SI joint fusion products. We are in the early phase of ramping up this business and will continue to train physicians in our field force throughout 2024.

As a result, we anticipate that the second half of this year will begin to reflect revenue traction in this business. As we communicated previously, while we continue to expect the Vyrsa transaction to be accretive to both revenue and adjusted EBITDA this year, we also expect the revenue contribution from our SI joint business to be immaterial to the overall year.

Turning now to our 2024 full year and second quarter guidance. First, for the full year 2024, we continue to expect worldwide revenue of approximately $435 million to $445 million. This reflects our outperformance in the first quarter, our expectations for the second quarter, which I will discuss in a moment, and our outlook for the second half of 2024. We expect gross margin to be approximately flat with 2023 gross margin of 68%.

Our Costa Rica manufacturing facility continues to produce excellent results with low labor and material costs for manufactured products. We remain excited about the cost improvements Costa Rica can deliver, and we continue to project long-term gross margins in the mid-70s, assuming pricing holds at current levels.

We expect our full year 2024 operating expenses to be approximately $390 million and largely flat compared with 2023. Keep in mind that our 2024 operating expenses also include restructuring-related charges of $10 million, Vyrsa related amortization and milestone revaluations totaling $6.5 million and key SI joint investments as we continue to scale this exciting new business. Excluding the above items, we expect our operating expenses to be down approximately 7% and on a year-over-year basis. In total, we expect our January and May 2024 restructuring efforts to generate savings of more than $25 million in 2024 and full year annualized run rate savings of well over $30 million.

Importantly, and as we mentioned in our Q4 2023 earnings call, through our restructuring and other efforts to drive improved efficiencies and expense management, we are redirecting portions of our resources to key areas of our business such as adjacent technologies, next generation R&D projects, investments in PDN and SI joint-related investments to deliver a world-class transfixing solution to patients. We are laser-focused on aligning our cost structure with our business and are taking additional restructuring steps to reduce our costs, improve efficiencies and focus our resources on executing our strategic priorities.

Given our outperformance in the first quarter and the actions we are taking this year to accelerate our path to profitability, we are raising our adjusted EBITDA guidance for the full year to be in the range of negative $5 million to positive $2 million, which roughly reflects a $9 million to $10 million improvement in adjusted EBITDA compared to the guidance we provided in February 2024.

For the second quarter of this year, we expect worldwide revenue to be in the range of approximately $106 million to $108 million, which is in line with our expectations for the first half of this year. As we have previously communicated, the SCS business can be a bit lumpy. While we are pleased with our first quarter performance, which exceeded our expectations, we still believe that our first half will largely finish in line with our initial expectations of approximately $208 million to $210 million, which is up 1.4% to 2.4% for the first half of this year versus the prior year period. We expect second quarter 2024 adjusted EBITDA to be in the range of negative $3.5 million to negative $2.5 million.

In closing, we are pleased with our first quarter performance and are excited about our future. We know we have more work to do, and we remain committed to executing our strategy, operating with an eye toward achieving profitability by capitalizing on significant growth ahead of us and aligning our cost structure with where the business currently stands to deliver value to our customers, the patients they serve, our employees and our stockholders.

Audra, we'll now open the call for questions.

Operator: [Operator Instructions] We take our first question from Joanne Wuensch at Citi.

Anthony Occhiogrosso: This is actually Anthony on for Joanne. I guess the first on guidance, just given where the second quarter is, it implies a pretty steep acceleration of sales in the back half of the year. And then similarly, for EBITDA, can you just maybe talk about what gives you confidence both in the revenue and the EBITDA number, maybe just talk about some of the cost cutting you're pursuing?

Kevin Thornal: Yes. Thanks for the question. Yes. So we do have it ramping in the back half of the year. As you recall, this business has a lot of seasonality with the fourth quarter always being substantially the biggest quarter of the year. So we predict that seasonality will continue. We also obviously have our SI joint business that will provide a little bit of tailwinds to us as we get into the back half of the year. And then also, don't forget, last year, we had a pretty big change in our sales force and people were hired towards the back end of 2023, so they're still ramping up as the year goes on. And a lot of those newer reps are starting to hit their stride out there in the field.

And we also, as we indicated, while it's still a small portion right now, but we have -- the people that have had a previous Nevro device that are coming back to continue their therapy after maybe 9, 10, 11 years of great success on the treatment still want to continue that therapy. So we see that progressing as the year goes on as well.

Anthony Occhiogrosso: And just a quick follow-up on your second point on the replacement opportunity. How much of that is baked into guidance for this year?

Kevin Thornal: Yes. Everything, trials and replacements and competitive conversions and new patients, are always baked into the guidance. So it's all baked in right now. We're not going to get into calling it out. It's a really small part of our business right now, and so we'll continue to include it as we give our guidance for the rest of the year.

Operator: We'll go next to Nathan Treybeck at Wells Fargo.

Nathan Treybeck: Can you provide a little more color on your '24 guidance assumptions? I mean you beat Q1 by about $4 million, but you didn't raise the full year guide. Q1 was also your toughest comp for the year. I guess are you assuming Q2 to Q4 lower than your initial outlook?

Roderick MacLeod: Yes. I mean, just mathematically, we overdelivered in Q1, and we're holding the full year at the same level. So yes, you're correct. We feel like Q1 was a touch stronger than what we were anticipating, and we're really -- as we look at the first half of the year, it's still really coming in line with how we initially thought the first half of the year would play out. So with the first quarter being a little bit stronger, second quarter is just a touch softer than maybe what we would have projected when we put that Q1 guidance out.

Nathan Treybeck: Okay. And can you provide a bit of color on the additional restructuring ourselves that you're taking? And do you expect more disruption from this through the rest of the year?

Roderick MacLeod: The short answer is, no, we don't expect much in the way of disruption. A lot of this was just driving increased focus on the projects and the strategies that, as an organization, we're really going after. And we were able to shed about $25 million in reductions for this year alone, on an annualized basis, it's north of $30 million. So a lot of good work by the team to just drive focus on really the key aspects and strategies of this organization.

Operator: Our next question comes from Robbie Marcus of JPMorgan.

Rohin Patel: This is actually Rohin on for Robbie. I just had a couple of questions. First on Vyrsa, I know you mentioned that you expect kind of tailwinds from the SI joint business in the second half of the year. Can you elaborate a little bit more on how much of that is baked into the guidance? I mean I think some prior commentary pointed to roughly $20 million in sales. How should we think about that just for the full year and also just quarter-to-quarter, that would be helpful.

Kevin Thornal: Yes. Thanks for that. Yes, we're excited about Vyrsa, but it is still a nonmaterial part of our business. We have never put out a number that's a $20 million number. So I want to make sure people don't think that we gave out any of those numbers because we have it. We still have to scale that business. A lot of it is around the sort of the internal scaling of making sure we have the trades that are utilized for the procedure and ramping those up. So our sales reps can have them available to them and available for the procedures.

And we also are making sure that we train physicians and our sales reps the right way. We go through a pretty exhaustive list of things that the reps have to show before they can start to cover some cases by themselves. And so it's going to take us some time to continue to get all of our sales reps up to speed. But as I mentioned, right now, we've trained over 220 physicians and the waiting list was much bigger than that. So we'll continue to add on SI joint training classes, but it does take time for physicians after they get trained to go back, identify patients and start doing those procedures. So we're excited about it, but it's nowhere near that size of the business as we move on through the year. As we said, it's going to be an immaterial part in 2024.

Rohin Patel: Got it. That's really helpful. And then the second one is just on gross margin quickly. You had a pretty solid gross margin in the quarter, came in out of expectations and still kind of expecting it to be roughly flat for the full year with 2023. So can you just walk through why you expect the sequential decline? Just given you had a strong quarter, you mentioned that a lot of it was due to the Costa Rica manufacturing ramp, which obviously should continue throughout the year. So just talk to some of the puts and takes there, that would be helpful.

Roderick MacLeod: Yes. If you -- happy to. It's a good question. And if you happen to go back to our last quarter, we walked through this a little bit as well on the call. But basically, as we're in this transition phase, moving from contract manufacturers to sourced product out of our Costa Rica manufacturing plant, there's going to be a couple of months where some of the variances associated with the overheads will hit in a little bit of a meaningful way in the second half of this year. And this really has to do with, prior year, when volumes and some of the mix shifted.

So we're going to take a little bit of a -- we're going to see some of those variances flow through in COGS in the second half of the year. But our long-term prognosis for the costs out of Costa Rica are still super strong. The labor rates are good. The material costs are good. And we're just going to have to work through a little bit of these choppy waters as we're transitioning from the contract manufacturer to Costa Rica manufacturing.

Operator: Next, we'll go to Shagun Singh at RBC.

Avi Dahan: This is Avi on for Shagun. Could you discuss the health of the spinal cord stimulation market in some detail? What's contemplated in your 2024 guide? And what can we expect never to get back into a share take position?

Kevin Thornal: Yes. Look at the -- we commented on the trials in the first quarter being largely in line with what we expected because of some softness in the trialing. What we know right now from the public companies that have announced is there's really 2 of us that grew in the quarter. One of our competitors announced being down in the quarter, but we believe there's a couple of private players that are also up. So 3 or 4 of us actually grew in the first quarter. So that's encouraging.

As far as what's baked into the guidance, all of our trialing replacements, everything we talked about, is baked into the guidance for the year, including ramping a little bit to our SI joint business in the back half of the year. Our sales reps ramping up throughout the year that were hired at the end of last year as well. As those replacement cycles still likely going to be strong for those patients that have had unbelievable success with our technology over the last 10 years. And so you add those all together, and they're all baked into the guidance and why we feel good about reconfirming guidance for the year.

Operator: We'll move next to Bill Plovanic at Canaccord Genuity.

Zachary Day: This is Zachary on for Bill today. On Vyrsa, was there any impact on Q1 revenue from that? I understand that you trained over 220 physicians, was there any that saw any volumes that impacted revenue?

Roderick MacLeod: Yes. As we've mentioned, we picked up a little bit of revenue from our SIJ business, but it's immaterial, and they'll continue to be immaterial as we're ramping up that business.

Zachary Day: Got it. And for my follow-up, you mentioned having R&D programs, new tech on the way in PDN. Could there be any integration with -- closed loop within your portfolio?

Kevin Thornal: Yes. So one of the things -- just a quick technology sort of education here. So high-frequency closed loop is not needed. So closed loop, a technology that Medtronic now announced, and one of the private players has out there, is basically to ensure that as the lead is next to the spinal cord, if it moves closer to or further away, that you don't get over therapy and maybe provide a little [ depth ], or further away or it moves further away, where you don't have a good enough therapy. That's their way of really turning up the volume up or down based upon where that lead is placed.

We don't have that problem with high frequency. It's like asking a Tesla owner where's your gas tank. We don't need one of those on high frequency because we already with doing paresthesia-free, we don't have to map the patient. And as a result of that, we've always had great parts of FDA approval where you can drive a car with our therapy, you can go out and have do activities with our therapy, because we don't have any of those jolts or reduction in therapy based upon the lead location.

Operator: We'll move next to Anthony Petrone at Mizuho Group.

Anthony Petrone: A little bit just on the competitive dynamics, and I have a follow-up on gross margin. Maybe just a little bit on Abbott's presence there with Eterna. They obviously have a potential synergy there with their Libre franchise on the diabetic side. Just wondering if they've changed the dynamic on the PDN side with a turn of potentially side-by-side with Libre. And then I have a quick follow-up on gross margin.

Kevin Thornal: Yes. So we've not seen that out there. There could be some potential where they would want to partner. We still stand by our clinical superiority that we have and the claims that we have with 10 kilohertz, specifically for PDN patients. If you think about it, and I've said this before, these PDN patients that suffer from painful diabetic neuropathy already have severe tingling and numbing in the leg, the last thing you want to do is add additional paresthesia to those patients. And with high frequency, we don't have paresthesia, that's not how our technology provides pain relief. And so it's a perfect choice for physicians treating PDN patients.

You can see that we've trained a ton of physicians that have these types of patients in their practice. We have a sales force that's out there educating those referring physicians into pain management offices, and we believe we'll continue to have superior outcomes clinically. As we talked about in the earnings script, with pausing our sensory study, we believe we may have a chance to have a powered study to be able to get additional claims in that space. And we know that we're the only ones doing that clinical work. So we believe we're still going to stand strong in that PDN market and lead the way.

Anthony Petrone: And just a quick one on gross margin fall. Maybe looking beyond 2Q, you do have HFX iQ at an ASP uplift and Costa Rica is going to be a meaningful contributor going forward, just as you look ahead beyond 2Q, I mean, how do we think about those 2 dynamics playing out in the second half and maybe even to 2025, the gross margin uplift from higher ASP and then Costa Rica manufacturing?

Roderick MacLeod: Yes. It's a good question. There's a couple of factors at play. And the way you're framing it is directionally right. One, the mix will continue to shift towards iQ. As Kevin mentioned, we finished Q1 about 58%. That was up from 53% of our mix being iQ. 58% in Q1, 53% in Q4. So that mix shift will continue, especially as we've been able to offer a solution to the Android users out there to use the app with iQ. We are picking up a little bit of a pricing premium on that product, and we expect to continue to do that.

For the second half of the year, as I mentioned earlier in the call, though, we are going to have a little bit of pressure on the COGS side as we have to run some of the variances through the income statement and through COGS in the second half of the year. But as we get into 2025 and beyond, that's when we start to see -- assuming the pricing holds, that there's some really strong opportunities to expand margins in 2025 and beyond as the COGS are coming in right in line with really how we think that this will play out over time. As I mentioned, labor costs are solid. Material costs are in the range that we expected. So we continue to be really excited about the quality and the scale that Costa Rica is delivering for us.

Operator: And we'll move next to Carolyn Huszagh at Bank of America.

Carolyn Huszagh Smith: This is Carolyn on for Travis. I wanted to follow up SI joint training disruption in the quarter. You've mentioned additional training sessions in the second quarter and then continuing throughout the year. So can you put a finer point on the cadence there? What do you expect for disruption in the second quarter when it comes to SI joint training relative to first quarter? And how does that disruption in the second half compared to the first half? And then I have one follow-up.

Kevin Thornal: Sure. Yes, most of these courses we do over the weekend, but a lot of times physicians have to travel in on a Thursday night or maybe a Friday depending upon where they're located to come to some of our larger trainings. We will eventually shift those out to more of a regional training, but right now our best to be able to bring in a large number to each of these training sessions. So that's baked in already to our guidance. We're not going to break out like what percentage, it's just it's a part of the overall.

And we know it's the right thing to do as these patients can benefit from having mechanical back pain relief on top of their neuropathic back pain relief that we have for our SCS products. And obviously, while they're there, [indiscernible] we have a chance to talk to them about our SCS therapy. So we're not missing out on a great opportunity to keep driving our superior technology and educating our physicians around it, but it does take physicians out of their office for a day or 2 and they'll obviously miss some trials as a result of that. It's not a massive number, but we just wanted to call it out as we know it had an impact within the quarter and likely a little bit in Q2 as well.

Carolyn Huszagh Smith: Got it. And then just putting a finer point on the source of the disruption between training Nevro sales reps versus training the doctors, should we think about this disruption as more of a one-time impact as your reps get up to speed and then they move past it? Or is this, I guess, perpetually a little bit more disruption than you expected previously? Is your expectation that you would continue to take doctors out of the clinic for a day or 2 moving forward to get them up to speed on SI joint?

Kevin Thornal: Yes. So what we're doing is we're actually training our physicians and their sales rep at the same time. So we're getting a 2 for 1 versus separating those trainings. And so we're able to have the physician and their sales rep stand side by side and making sure that they're training appropriately. So when they go back together to their practice, they can form that procedure just like they did on a model or cadavers. And so we are getting sort of 2 for 1 as we do these training sessions.

And most of our sales reps right now -- we're working through getting at least one person in each territory where they're sort of certified, as we call it, to make sure that they can cover cases appropriately, and we're well on our way to do that. So it's really a bolus of training right now, where we have a lot of our Nevro SCS and planning physicians that wanted to be first in line to really train for SI joint. And we made sure that they were sort of front of the line there, and our sales reps that cover those territories were sort of the first in for training. We believe that by the end of Q2 and throughout Q3 a bit, we'll get the majority of our sales reps up to speed where at least one person in that territory can help cover those cases.

Operator: We'll go next to Justin Lin at William Blair.

Justin Lin: First one on HFX iQ, what's the timing in terms of getting it available on Android like you talked about? And are there any other levers that you can kind of pull to accelerate that growth on top of the Android dynamic?

Kevin Thornal: Yes. So we just launched an opportunity for patients that had Android. It's not on their device, it's a locked iPhone that they're able to utilize for the treatment. And that way, it stays consistent across all of our customer base. As a reminder, we are the only company that has AI inside of our technology with our algorithm because of the 100,000-plus patients that are in our database. And we want to make sure that, that data that we get from all of our patients, we keep learning and our algorithm keeps adapting based upon how patients are receiving their treatment and that treatment is personalized for them. So we just launched that within the quarter, and that's being rolled out across the U.S. right now.

Justin Lin: Got you. Second follow-up question just on PDN. I know you're no longer kind of bifurcating out the PDN business, but any qualitative color you can give there, how is the business trending relative to your expectations?

Kevin Thornal: Yes, it came in right in line with our expectations. It's still strong. Still have a ton of interest. And again, we're still around 1% penetrating in that market. And so we're out there educating every day on the benefits of the therapy and ensuring those referral networks are set up. So it will continue to still be a strong part of our business moving forward. But it came in right in line with our actions and it was still strong.

Operator: And next, we'll go to Brad Bowers at Mizuho Securities.

Bradley Bowers: I just wanted to follow up on one from Mizuho and on behalf of Anthony. Just wanted to go back to the Vyrsa strategy. It sounds like a lot of the work being done right now is on existing Nevro physicians and getting them trained, but it's sounds like the longer term or medium to longer-term strategy is for Vyrsa to be used as kind of a door opening tool to get into practices where Nevro maybe isn't the majority choice for SCS.

So just wanted to hear when do you think you'll be able to kind of switch the sales force to focus on new accounts and leading with Vyrsa SI and trying to take some market share back in the pain practices? Is that something that will be maybe a help for the numbers this year? Is that something that maybe we should consider more of a next year item?

Kevin Thornal: Yes, for sure. I mean a lot of our sales reps have already taken advantage of the opportunity to have conversations with physicians that maybe had told them no over a period of time, and now they have something new to talk about. So we're excited about those physicians in the queue for training. Obviously, the results we were talking about today were a lot towards Q1. But as we're already into Q2, the mix shift to physicians attending our trainings are including all comers, so Nevro physicians that have put SCS and Nevro devices in for a decade, and some that are implanters of other devices for SCS and also learning the Nevro1 device. So we'll do a lot of both.

Operator: And that does conclude our Q&A session and today's conference call. We thank you for your participation. You may now disconnect.