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Vericel (NASDAQ:VCEL)
Q3 2021 Earnings Call
Nov 09, 2021, 8:30 a.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Operator

Ladies and gentlemen, thank you for standing by. Welcome to Vericel's third quarter 2021 conference call. At this time, all participants are in a listen-only mode. I would like to remind you that this call is being recorded for replay.

I will turn the conference call over to Eric Burns, Vericel's head of financial planning and analysis and investor relations. Please go ahead.

Eric Burns -- Head of Financial Planning and Analysis and Investor Relations

Thank you, operator and good morning, everyone. Welcome to Vericel's third quarter 2021 conference call to discuss our financial results and business highlights. Before we begin, let me remind you, on today's call, we will be making forward-looking statements covered under the Private Securities Litigation Reform Act of 1995. These statements may involve risks and uncertainties that could cause actual results to differ materially from expectations and are described more fully in our filings with the SEC, which are available on our website.

In addition, all forward-looking statements represent our views only as of today and should not be relied upon as representing our views as of any subsequent date. Please note that a copy of our third quarter financial results press release is available in the investor relations section of our website. We also have a short presentation with highlights from today's call that can be viewed directly on the webcast or accessed on our website. I am joined on this call by Vericel's president and chief executive officer, Nick Colangelo; and our chief financial officer, Joe Mara.

I will now turn the call over to Nick.

Nick Colangelo -- President and Chief Executive Officer

Thank you, Eric and good morning, everyone. Despite additional COVID-19 headwinds in the third quarter, the company delivered solid commercial and operational results and continued to generate top-line revenue growth, positive adjusted EBITDA and operating cash flow for the quarter. The spread of the Delta variant and the resulting disruptions to healthcare networks and patient behavior dynamics clearly impacted MACI revenue in the quarter. However, the key underlying growth drivers for MACI remained very strong and Epicel had another outstanding quarter with revenue growth of nearly 50% compared to the third quarter of 2020.

Importantly, from a profitability perspective, the company generated positive adjusted EBITDA and operating cash flow for the fifth consecutive quarter as we continue to drive top-line growth while delivering sustained profitability and cash flow. With respect to MACI revenue, based on historical seasonality patterns, for the second half of 2021, we expected the typical sequential decline in the third quarter revenue and strong sequential step up in the fourth quarter. During the third quarter, we saw a significantly greater decline in July than in recent years due to patients deferring procedures as the economy reopened and travel and vacations resumed. While we assumed that we'd start to recapture some of those deferred cases later in the quarter, the expected improvement in the second half of the quarter did not materialize due to the Delta variant resurgence in various regions of the country.

The impact on MACI activity was most pronounced in the areas of the country that had the highest COVID-19 case rates and some of our best performing territories are in those regions. Importantly, MACI biopsy growth as was the case in prior periods of COVID-19 disruption, continued to outperform implant growth. We estimate that as a result of the reopening dynamics and the Delta variant surge, we exited the quarter with a backlog of approximately 150 cases that would have converted to implants under normal conversion patterns, which equates to about $7 million in revenue. We had similar levels of backlog during the initial COVID-19 lockdown in the spring of 2020; and again, last winter.

And in each instance, we recaptured more than 80% of the backlog cases within one to two quarters. We expect to recapture a similar percentage of the current backlog, although due to continued uncertainty regarding COVID-19 disruptions for the remainder of the year, we believe that this recaptured likely will be more gradual and that the majority of these cases will move into 2022. Even So as Joe will discuss in more detail, we've seen an acceleration of MACI orders in the fourth quarter and we expect the highest sequential growth in MACI revenue from Q3 to Q4 since launch and record quarterly revenue to close the year. From an operational standpoint, we're very pleased with the results that we've generated to-date with respect to the key underlying growth drivers for MACI, which we believe support its long-term high growth profile.

We remain on track to grow the number of surgeons taking biopsies by more than 20% this year to approximately 1,800 surgeons, which is a key growth target for the year. Biopsies per surgeon, another key growth driver are projected to grow approximately 10% compared to 2020 and overall biopsy growth is expected to exceed 30% for the full year. Looking forward to 2022, we expect continued double-digit growth in biopsy surgeons, an increase in biopsies per surgeon based on continued MACI uptick and the return of more normal patient flow, a normalization of biopsy conversion rates and the timing thereof. With all of our key growth drivers expected to continue to progress in 2022 and with potential for backlog carryover, we expect an acceleration of MACI growth in 2022, assuming that COVID-19 trends do not change materially.

We've also achieved important reimbursement enhancements for MACI this year that have further bolstered an already strong reimbursement profile. As a result of the expansion of United Healthcare's medical policy to include patients with patella defects, the number of United Healthcare fatalities has more than doubled through the third quarter of this year, compared to 2020. In addition and as ASC Payment System Final Rule issued last week, CMS determined that MACI is one of a small number of procedures that were added to the ASC covered procedure list last year that will remain on the list for 2022. This determination was based on meeting the reinstated general standards and exclusion criteria for the list, as well as the fact that the routine procedures are largely performed in an outpatient setting and that advancements in clinical practice and less invasive techniques are contributed to allowing these procedures to be safely performed in an ASC setting.

While we have limited Medicare business, this determination is important. And that certain commercial plans refer to these CMS rules in determining allowable sites of care, so that having MACI on the ASC covered procedure list provides greater flexibility for our customers in selecting the preferred site of care for MSCI procedures. Finally, we are also making significant progress of key life cycle management program for MACI, the development of a custom arthroscopic delivery system, which we believe is another important step in our strategy of continuing to make MACI even simpler and less invasive for surgeons and patients. We believe that arthroscopic MACI could be a significant mid-term growth driver to further penetrating the $2 billion MACI addressable market by increasing our physician targets beyond those that perform only open procedures and by increasing the number of procedures performed by current MACI surgeons.

We're in the process of finalizing the design of these instruments and we've received very positive feedback from key opinion leaders in the field. We look forward to providing additional details on this important program in the near future. Turning to our burn care franchise. We had another outstanding quarter for Epicel, achieving 48% growth in revenue compared to the third quarter of 2020 and the fourth straight quarter with over $9 million in revenue, which has led to 77% revenue growth year-to-date for Epicel.

We continue to see strength across the key growth drivers for Epicel with significant increases in the number of burn centers taking biopsies, the number of patients treated with Epicel and the number of grafts per patient. Given the strong commercial performance, we believe that we're well-positioned to deliver sustained penetration into our expanded addressable market, as we continue to build the second high-growth franchise into a more meaningful part of our overall business. Turning to the NexoBrid BLA. We recently participated in a productive Type A meeting with the FDA and there is agreement on the path forward to address the questions, issues and information requests from the FDA.

The Vericel team is leading this next phase of work in partnership with MediWound and we currently are targeting a BLA resubmission in mid-2022. We remain very enthusiastic about adding NexoBrid to our burn care franchise and look forward to potentially bringing this innovative product to the market as expeditiously as possible. I'll now turn the call over to Joe to discuss our third quarter financial results and updated financial guidance.

Joe Mara -- Chief Financial Officer

Thanks, Nick. Starting with the income statement. Total net revenue for the third quarter increased 7% to $34.5 million, compared to $32.3 million in the third quarter of 2020 and included $23.9 million of MACI revenue and $9.8 million of Epicel revenue compared to $24.4 million and $6.7 million of MACI and Epicel revenue respectively in the third quarter of 2020. Total revenue for the quarter also included approximately $0.8 million of revenue related to the procurement of NexoBrid by BARDA for emergency response preparedness.

For the third quarter of 2021, total net revenue increased 38% to $108.6 million compared to the same period in 2020 with MACI revenue increasing 24% to $74.2 million, Epicel revenue increasing 77% to $31.8 million and $2.6 million of revenue related to the BARDA procurement of NexoBrid. As Nick discussed earlier, MACI's third quarter results were impacted by COVID-19 headwinds. Additionally, when comparing third quarter MACI revenue to Q3 2020, it is important to keep in mind that the third quarter of 2020 was positively impacted by a significant catch-up after the initial COVID-19 related lockdowns, which impact the year-over-year comparison. We estimate that approximately $5 million of MACI revenue in the third quarter of 2020 was related to the cases that shifted from the prior quarter due to the initial COVID-related restrictions on elective surgeries.

So while MACI revenue was down 2% for the quarter on a reported basis, the underlying growth was over 20% excluding this estimated $5 million catch-up in Q3 of 2020, which is more consistent with the year-to-date MACI growth. Gross profit for the quarter was $22.1 million or 64% of net revenue compared to $22.5 million or 70% of net revenue for the third quarter of 2020. The reduction is primarily due to higher non-cash stock compensation expense related to a higher share price, an increase in manufacturing headcount and our product mix. Total operating expenses for the quarter were $27.1 million compared to $19 million for the same period in 2020.

The increase in operating expenses was primarily driven by higher non-cash stock compensation expense, as well as a normalization of spend across all areas of the business as compared to the constraint spend in 2020 due to COVID-19 related factors. Net loss for the quarter was $4.9 million or $0.11 per share compared to net income of $3.6 million or $0.08 per share for the third quarter of 2020. Non-GAAP adjusted EBITDA for the quarter was $4.3 million or 12% of net revenue compared to $6.8 million or 21% of net revenue in the third quarter of 2020. Finally, we generated approximately $4 million of operating cash flow in the quarter.

And as of the end of the third quarter, the company had approximately $119 million in cash and investments compared to $100 million as of December 31, 2020 and no debt. Transitioning to our updated financial guidance for 2021. Our previous guidance for MACI assumed that biopsy conversion rates and the timing of conversions would generally be in line with historical patterns or at least normalize by year end and that COVID-19 dynamics would not materially change those patterns versus prior years. With the recent COVID impacts that Nick mentioned earlier, we exited the quarter with a backlog of approximately $7 million worth of cases that in a normal conditions would have converted from biopsy to implant this year.

And given this disruption in the second half of the year, we now anticipate that conversion rates will not fully normalize until next year and that the majority of our incremental backlog will convert to new cases in 2022. Based on these COVID related dynamics, we are updating our MACI guidance in 2021 being in the low 20% growth range for the full year. This change to our full year guidance mainly reflects our updated expectations on the timing or calendarization of when cases will convert to implants. Not a decrease in underlying demand as demonstrated by our surgeon and biopsy growth.

Although COVID headwinds remain, we have seen an acceleration in MACI ordering patterns to start Q4 and our updated guidance for the fourth quarter implies what would be a sequential increase of over 64% from Q3 to Q4, which represents the highest sequential increase since the launch of MACI and also would represent the highest MACI revenue quarterly revenue to-date. With the majority of the incremental biopsy backlog now expected to convert to implants next year, as well as the increases in the other key MACI growth drivers that Nick discussed earlier, we believe that this should allow for a further acceleration of MACI growth in 2022, with MACI full year growth next year expected to exceed this year's overall growth rate. Moving to Epicel. Our updated guidance now anticipates growth for the full year to be in the low 50% range with over $40 million in full year revenue.

This revised Epicel guidance represents a full year growth rate of approximately 3x our initial growth rate expectations to start the year and a further increase versus our most recent guidance, as our year-to-date results for Epicel of approximately $32 million have already exceeded our full year results in any prior year. Finally, we expect approximately $3.3 million of NexoBrid BARDA related revenue for the full year. In total, this brings our full year 2021 revenue guidance roughly back to where we started the year, which at that time did not assume significant headwinds from COVID-19. We now expect total revenue in the $158 million to $161 million representing full year growth in the range of 27% to 30%.

Apart from 2020, which was more severely impacted by COVID-19, this would continue Vericel's strong track record of generating over 25% growth for the company each year since the launch of MACI. With our updated revenue outlook, we now expect full year gross margin to be approximately 70% and full year adjusted EBITDA margin to be approximately 22%. We expect for your operating expenses to decrease to approximately $114 million, slightly below our previous guidance of $115 million. Importantly, our adjusted EBITDA guidance for the full year would essentially double our adjusted EBITDA of approximately $19 million in 2020, demonstrating the continued strengthening of the overall financial profile of the company.

And looking forward, we expect that both our gross margin and adjusted EBITDA margin will further increase next year as the company's profitability profile continues to progress. This concludes our prepared remarks. We will now open the call to your questions.

Questions & Answers:


Operator

[Operator instructions] Your first question comes from Ryan Zimmerman with BTIG.

Ryan Zimmerman -- BTIG -- Analyst

Hey, good morning. Thanks for taking the questions. So I want to ask first on MACI biopsies a little bit. I kind of appreciate the conversion dynamics kind of pushing into the next year.

But you guys were on-track, I think for greater than 50% growth in the past and the first half '21. Now you're talking about maybe 30% growth for the year. So can you just discuss kind of what you saw this quarter and then what your expectation really is on biopsies in fourth quarter based on your run rate for the year?

Joe Mara -- Chief Financial Officer

Yes. Thanks, Ryan. This is Joe. I'll start and Nick can chime in.

So I think in the last call, what we talked about was through the first half of the year, we'd seen roughly 50% or more when you look at that year-to-date biopsy growth. And I think as we -- I would also say, on the last call we talked about MACI kind of in that 30% plus range on revenue. So there certainly was a bit of a disconnect as we were seeing the biopsies come through in the first half of the year and that was compared to 2020, which obviously had some COVID impact in the first half of the year. When you look kind of more broadly, what we're saying is on a full year basis now we expect biopsies to be over 30% for the full year.

And, I would say, in the third quarter, we did see some disruption in the healthcare systems, but biopsies were kind of close to what we saw in the prior quarter. And I would say, if you look kind of at the first three quarters of the year and you compare those to 2019, which is probably a cleaner comparison, you see growth rates of over 30% across all those quarters. So you kind of put that together and I think that gives you a sense of where we are year-to-date and also the 30% being what we expect on the full year.

Ryan Zimmerman -- BTIG -- Analyst

OK. And then Epicel is becoming a more material portion of the business. I think back a few years and that necessarily wasn't the case. But now the growth rates have become pretty material.

And So Nick, as you think about Epicel next year in a normalized environment, how do you think about the growth rate that can sustain for an Epicel-like product that you're now seeing such growth from?

Nick Colangelo -- President and Chief Executive Officer

Yes. Thanks, Ryan. So obviously this has been just an outstanding year for Epicel. And as we continue to focus on sort of the growth drivers of increasing the number of biopsy-ing and grafting, burn centers treating more patients and maintaining that higher utilization of grafts per patient, that will form the basis for the growth going forward.

So I think, it'd be sort of silly to say, we'd expect 50% growth year over year. But we certainly expect Epicel to continue to grow, as we've sort of broadened the user base and then have deeper penetration into those centers. So we're not prepared at this point to give guidance for next year. We'll do that sort of early next year.

But we certainly do expect continued growth for Epicel in the years ahead.

Operator

Your next question comes from the line of Jeffrey Cohen with Ladenburg Thalmann.

Jeffrey Cohen -- Ladenburg Thalmann -- Analyst

So a few familiar ones. So firstly, could you talk about United and patella defects and give us a sense of what percent of your revenues that may be or how large the patient pool is?

Nick Colangelo -- President and Chief Executive Officer

Yes. So as we mentioned earlier this year, Jeff, we did -- United Healthcare did expand its medical policy to include patella cases. And the way we sort of wanted people to sort of think about that as, United Healthcare is the largest commercial payer in the U.S., right? Representing about 15% of commercial lives. And I think what we've said is, basically the approval rates now for United cases for patella are basically on par with other plans and non-Patella cases.

So I think you can kind of just at a high level think about what percentage of our business would be United. Well, if it covers, if they're the largest payer covering 15% of covered lives, that's probably a good proxy, in terms of how to think about our portion or the portion of our business that is represented by United Healthcare now be it a patella case or a non-patella case.

Jeffrey Cohen -- Ladenburg Thalmann -- Analyst

And could you talk a little bit about the arthroscopic delivery tool? Would that be a Class 2 filing? And what would you expect as far as uptake from the surgeons out there? Would you expect that to turn into a majority of cases or maintaining the minority?

Nick Colangelo -- President and Chief Executive Officer

Well, I don't -- I think it's a little premature to sort of forecast what percentage of the cases would be done arthroscopically versus through the mini-arthrotomy. I think taking a step back, this is another step on the path that we are taking with this franchise where when you moved from Carticel to MACI, you took a highly invasive procedure, made it less invasive. Over the past couple of years, we've had basically sizing tools available for more uniform sort of defect debridement and then implant and that sort of -- has become very popular. And then of course, arthroscopic as a less invasive and potentially even simpler procedure, it just continues on that journey.

And you see this in the industry often, right? Where you take these highly invasive surgeries, turn them into minimally invasive surgeries and that's what fuels the growth. And so that's the path we're on. Last year, we talked about the fact that first thing you want to do is be able to demonstrate that you don't impact cell viability through arthroscopic delivery. We've been able to do that through our feasibility studies and demonstrate that you can meet minimal cell number and other relief criteria for MACI when it's delivered arthroscopically.

The next part of the project is sort of designing instruments and we've been working very closely with a group of our KOLs on instrument design over the course of this year. And we expect to kind of finalize the design of the instruments by the end of the year, whether it's a Class 1 or Class 2 device will depend on whether the disposables are reusables, that's a question we're still considering. And So we're very pleased with the prospect of arthroscopic delivery method. Obviously, as I mentioned, there's sort of two dimensions to that.

One is there certainly are surgeons who only do open procedures, but do high volumes of cartilage repair. And so that obviously, could open up part of the addressable market for us. And then, there certainly are current MACI users who may identify additional patients. We believe that would be the case when an arthroscopic alternative delivery is available.

So we're excited about it and we'll provide more details early next year as we continue to proceed with the project.

Jeffrey Cohen -- Ladenburg Thalmann -- Analyst

And then lastly, could you talk about any activities or any ongoing activities outside the U.S. for other -- the two products as far as any channels or agreements in place?

Nick Colangelo -- President and Chief Executive Officer

Yes, So we're principally focused as Jeff on the U.S. MACI, when we acquired this business years ago, was approved in the EU, very challenging market for these advanced cell and gene therapies, would have required some manufacturing changes to our plant here in the U.S. which we weren't going to sort of impact U.S. production for those opportunities.

As we think more broadly, down the road, as we continue to expand capacity, we certainly can design facilities and clean rooms to meet sort of European requirements. And that may allow us to go back to Europe. So again, I think the U.S. market by far dominates the opportunity for MACI.

And same thing for Epicel, because of the shelf life of Epicel, if we were to go outside the U.S. we'd essentially have to build a manufacturing facility in whatever geography that would entail. And So I think it's fair to say, at least for these two products that we'll remain focused on the U.S. market, which again provides the greatest opportunity.

Operator

Your next question comes from the line of Daniel with SVB Leerink.

Unknown speaker

Just a question, I appreciate, you're not going to give 2022 guidance. But talking about MACI biopsy growth rate of 30% plus this year, why is that not the right way to think about then MACI growth for next year? Are there some other dynamics at play here? I appreciate the conversion rate, but as long as the conversion rate doesn't get materially worse and you've got the backlog, maybe arguably the conversion rate could be better. Is that the right way to be thinking about the growth outlook in 2022? And then I have one follow up.

Joe Mara -- Chief Financial Officer

I'll start Daniella, this is Joe. So I think we're not really ready to give guidance on 2022 as you've alluded to. But, I think kind of broadly speaking, we certainly talked about in the prepared remarks, we expect continued double-digit growth in the number of surgeons, which is a key driver. We expect the biopsies per surgeon to also increase.

We do expect a normalization of the biopsy conversion rates and do have that backlog moving into next year. So certainly I think broadly speaking, we're kind of in the 20s this year, in the low 20s on the full year right now, based on kind of where we're ending the year. So I think, directionally, I mean, these kind of pieces are pointing us to a higher growth rate, but the absolute number it's kind of hard to say, but certainly biopsies will also be part of it, as we think about 2022.

Unknown speaker

OK. That's helpful. And then just a quick question on sort of where we are -- and I know this is probably unfair given the fact that we're dealing with COVID-related headwinds. But MACI has been on the market now for several years and I'm just curious about Nick if you could sort of phrase for us what inning you think we were in the MACI launch? And I asked this because the discussion about seasonality in Q3 -- when a product is still pretty early in the adoption phase, you're usually not dealing with seasonality as much.

So just curious about what you could say on where we are in the MACI launch? Thanks so much.

Nick Colangelo -- President and Chief Executive Officer

Yes. Thanks, Daniel. So we certainly believe that we remained in sort of the early innings, maybe it's the third inning rather than the second, as we used to say. But as you think about the growth drivers for the company and we focus obviously on increasing biopsy-ing surgeons as the primary growth driver, as we've expanded salesforce, this is the first full year that we've had our expanded salesforce in place.

And, we expect to increase those biopsy-ing surgeons, as we said, by 20% up to 1,800. And if you look back to 2019, as we often talk about, at that point we were in our third year of launch, relative to our initial 3,000 target and even in that year, we had grown 25% in terms of the biopsy-ing surgeons and grown to about 50% penetration and even more on a cumulative basis. So we think there is still years of growth on biopsy-ing surgeons ahead. And then the other dynamics that we talk about, we expect will then kind of become the dominant growth drivers and that's increasing biopsies per surgeon, which absent any COVID disruption, the surgeons have full schedules.

So if you're getting more biopsies per surgeon, it's because they're identifying more patients that they believe are good candidates for Epicel. And again, we will see growth versus last year. This year we expect more growth next year and that to continue as well. And then, conversion rates, once they normalize post COVID-19, we expect to increase because our sort of more experienced or higher volume surgeons certainly have a higher overall biopsy conversion rate.

So putting all that together and knowing that there is no like competition coming down the pike, we expect years of growth for MACI going forward.

Operator

And your next question comes from Sam Bordovsky with Truist.

Sam Bordovsky -- Truist Securities -- Analyst

Hi. Thanks for taking the questions. I'll just ask too on the salesforce here, start with the MACI side of the business. Just will be curious to hear how you think about the newer reps there in terms of where they are relative to peak productivity? And then sort of more broadly, how you think about peak productivity for that side of the salesforce, access some of the productivity gains that were made last year with some of the new tools introduced there?

Nick Colangelo -- President and Chief Executive Officer

Yes. I'll take that Sam and Joe can add any additional commentary. But, we have made comments since expanding our salesforce. We had our largest salesforce expansion in 2020, going from 49 to 76 reps and throughout even this disruptive period, starting back in Q3 last year, we had mentioned that, that cohort of sales reps actually were sort of leading the country in terms of growth in new biopsy-ing and implant surgeons, which is what you would expect when you're bringing sort of highly experienced sales reps on board and that continues to be the case.

So we are very pleased with that expansion. And quite frankly, by the time we get to the end of next year, we will be looking again to say, are there additional targets and would a further expansion potentially be justified. But that'll be sort of a end of next year activity as we -- when we expanded a couple of years or last year, we expected this expansion to last us for a few years. So feeling really good about sort of their contribution to-date.

When you think about the productivity per rep, we had gotten to about $2 million per rep in 2019. As we expanded, we said that would fall back to sort of the lower end of the range of about $1.7 million, which is where we were back in 2017. But then, absent COVID would have expected to exit 2020 sort of on a $2 million run rate. And that got pushed out because of COVID-19.

But, we expect sort of be back there this year or at the end of this year as we exit 2021. And you can just kind of look at consensus estimates with 76 territories. If you're around $150 million in MACI revenue, then you're kind of right back to that sort of productivity level of a couple of million dollars per rep. And we don't expand further from that and continue to grow with the rates that we expect.

Obviously, the productivity per rep will go up from there.

Sam Bordovsky -- Truist Securities -- Analyst

Great. And then just on the Epicel side of business. If there's -- sorry if I missed this. But any updates there in terms of how the -- where we're at in the expansion of the salesforce and how we should think about that moving into '22? Thank you.

Nick Colangelo -- President and Chief Executive Officer

Yes. So we'd talked sort of at the end of last year on our investor day about sort of the full expansion plans ahead of a NexoBrid launch. And at that time, we had about seven territories for clinical support specialists and ultimately ahead of the NexoBrid launch, we'd expect to be more in the low 20s range with about, call it 14 territories or 12 territories and the clinical support specialist and the management team. Given sort of this super strong ramp with Epicel, we have added a few positions over the course of the year and we're up to about seven territories, six clinical support specialists, a couple of management leaders.

And so that's kind of where we are now. And as we progress through next year and the timing of a potential NexoBrid launch becomes clearer, we'll complete the expansion ahead of that. And I think it will be roughly in the range that we contemplated further, but of course, we'll take a look at that.

Operator

Your next question comes from Swayampakula with H.C. Wainwright.

Unknown speaker

A couple of quick ones. The first one is -- actually really appreciate Nick for explaining some of the issues that you folks faced because of the COVID-19, especially for MACI. In those comments you said, some of your best performing areas were impacted by the pandemic during the third quarter. So any commentary on those specific areas, how they're -- what are they experiencing in the fourth quarter now?

Nick Colangelo -- President and Chief Executive Officer

Yes, well, I think, as we've both experienced and kind of discussed it this morning, there were kind two ends to COVID disruptions in sort of the summer and throughout Q3, right? One was sort of this reopening dynamic as the economy reopened and folks were traveling and so on. And so kind of a patient-driven sort of determination on timing of sort of when they would go in for a MACI surgery. Again, we expected that once that sort of waned, you'd kind of have a recapture, but that's exactly sort of when the Delta variant surged, in obviously, the Southeast, Southwest, parts of the Midwest and West. And So that's kind of what drove sort of the dynamics we described earlier.

I'd say, from a patient perspective, that's probably -- I think probably mostly come and gone. I think patients make individual decisions and it's hard for us to sit here and opine on that. I'd say from the other aspect, which is where there are restrictions on either a healthcare system wide basis or individual institutions, we certainly saw some of that as was widely reported in the third quarter. So you had either individuals -- there were no statewide restrictions like there were back in 2020, but you certainly saw individual healthcare systems or individual institutions either pausing elective surgery for some period of time or restricting the number of elective surgeries that surgeons could do in those facilities.

And so that was clearly happening sporadically around the country. And for the most part, I think those have pretty much been resolved. So we don't expect to see too much of that in the fourth quarter, but again we can't sit here and predict what happens over the next couple of months.

Unknown speaker

OK. Thank you for that. If I heard it correctly, you said that there is a backlog of approximately 7 million sitting now, which you think could be spread more into the -- I'm guessing it's first quarter of '22. If it is first quarters of '22, generally -- look first quarter is one of the weaker quarters, right? And if I look at it historically -- if I'm looking at these numbers correctly.

So do you think the backlog will -- you think the first quarter of '22 look better than what it has been historically?

Joe Mara -- Chief Financial Officer

Yes, so RK. This is Joe. So I would say -- at this point, I would say it's quite difficult to predict exactly how those cases kind of flow through. Certainly, I think we are thinking about first half and certainly the first quarter is part of that.

But again, I think as we get into the guidance conversations next year, I think we'll have a better sense in terms of the seasonality. But I think in general I think it's the right way to think about it. It's probably first quarter and likely second quarter based on kind of what we've seen before. And it really just depends on kind of when and how things normalize from a healthcare perspective and a COVID perspective as well.

Unknown speaker

OK. Thanks for that, Joe. One last question for you. You said during the third quarter of 2020, there was a $5 million catch up, so this could impact -- I mean it is impacting the year-over-year metrics.

Can you comment on what was the catch-up among during the fourth quarter of '20, so that we're better prepared going into this quarter?

Joe Mara -- Chief Financial Officer

So can you repeat the last part? I know you're asking about the $5 million catch-up. But can you just you clarify the question for me?

Unknown speaker

What was the catch-up in the fourth quarter of 2020? If there was some.

Joe Mara -- Chief Financial Officer

No, I think what we were talking about was, it was the third quarter of 2020, when you're looking at that -- when we're looking at the third quarter of 2021 or current results, when you compare that to the third quarter of 2020, we were saying that, that had some impact of kind of that V-shaped recovery, which is really impacting across the metrics, across the business, including the revenues for Q3, impacting year-over-year comparison. So it was more about Q3 of 2020.

Unknown speaker

Yes, I got that. I was just trying to see if you have identified any anomaly in the fourth quarter of 2020?

Nick Colangelo -- President and Chief Executive Officer

Yes. So RK, as we have a slide in our accompanying presentation on Slide 6, it kind of gives you the recovery periods for not only the initial surge in the spring of last year, but what we saw over the winter this year. And sort of the difficult part in answering your question is, it wasn't just a fourth quarter sort of activity, right? We mentioned on our call that the last two weeks of December, we didn't sort of have the case of schedule as they might have in the past. And that sort of drifted into January and early February.

So you didn't have kind of a clean break of quarters to say, hey, it all -- the second surge ended in December and what happened in the first quarter of 2021. So it's a little hard to kind of pinpoint it with that degree of accuracy given it crossed quarters and years. But I think to Joe's point, we expect this recapture to happen in the first half of the year and it's a little hard for us to opine when sort of individual patients are going to decide that they want to move forward.

Operator

Your next question comes from Chris Cooley with Stephens.

Chris Cooley -- Stephens Inc. -- Analyst

If I may, want to touch just briefly the MACI shortfall in the quarter. Fully appreciate the COVID headwinds that were there. But curious, if you see anything underlying this additionally and specifically, I'm referring to maybe changes in physician practice protocols, I know we've seen some clinician shift, more of a bias in favor of single versus multiple use on HA. Just curious if you're seeing any subtleties like that in terms of the way that physicians are thinking about addressing these patients, either from a staging perspective or pulling them through the process that might've made this a little bit more pronounced? Because I think to Daniel's prior question, again, just seasonality at this stage of the game, just trying to make sure we fully understand what's behind all the numbers in the 3Q and the 4Q.

And I have a quick follow up. Thanks.

Nick Colangelo -- President and Chief Executive Officer

Yes. Thanks, Chris. I'll just start with sort of what we see from a physician, patient perspective and then Joe can kind of revisit the seasonality question. As I mentioned, there is kind of, I guess at least two dimensions to sort of the COVID-19 impacts.

One is, physician-based and/or institution based. And from a physician perspective, we haven't seen any sort of impact on physician enthusiasm for MACI. And I think that's reflected in the kind of biopsy-ing surgeon growth that we've seen and expect to continue to see. And that's really the best parameter of physician interest in this product, which is great.

Again, there were some institutional issues that they have to navigate around, right? When their institutions either sort of pause or limit the number of elective surgeries as things were really flaring up in what was arguably a pretty significant, as we all know, Delta variant surge. So that is out of the physician's control as well. So no impact sort of from a physician enthusiasm perspective from our standpoint. I will say, the other piece of the dynamic is, sort of patient behavior dynamics that we referenced.

And I will say that, as we talk and have sort of surveys with our key opinion leaders, I think they struggled in the third quarter. And even as early as May to sort of get patients to come in and have surgery, as patients were finally able to sort of come out of the restrictions, the general restrictions, travel and do the things that people like to do. And I actually think it was much more dominated by patient behavior and choices of when they want to have their surgery than anything to do with surgeon. So I agree with you.

And the underlying premise of Daniel's question, which is, it's kind of remarkable that we're coming into our 50 year since launch and you're still seeing this kind of uptake among surgeons and enthusiasm, it's great. And I think given that we now have 5,000 surgeons that we think are great targets, we think it's going to continue to grow from a surgeon perspective. So I'll end there. And Joe, you can add a comment on sort of what this growth in surgeons and biopsies mean for our outlook next year and going forward?

Joe Mara -- Chief Financial Officer

Yes. I think to the earlier question, certainly with the underlying growth drivers from there, we think this can continue to drive growth not only in 2022 and beyond. We talked about that a bit earlier. And I think just back on kind of the seasonality and the mix question that I think you're referencing Chris and Daniel had, just to make sure we answered that.

If you kind of look back historically on MACI, I mean, it's been pretty consistent in the fourth quarter kind of in that 35%-plus range in terms of the mix of business. And if you look at the guidance, I think it's similar to that as well this year. So I think there's -- just from a seasonality perspective, just the way kind of physician and patient behavior even pre-COVID and then into COVID, we're still seeing that uptake in the fourth quarter. So at this point, I think, just given some of the kind of physician and patient behaviors, as well as some of the kind of reimbursement dynamics that play at the end of the year, we're still seeing that seasonality and still expect that certainly for the foreseeable future.

Chris Cooley -- Stephens Inc. -- Analyst

And just very briefly for me. I know this call has gone over an hour now. But just curious on the NexoBrid resubmission targeted now for mid-June next year in 2022, just curious if you could provide any additional color there around your confidence in that resubmission, anything else that has to be done between now and that filing time? Apologize if I missed that earlier. But just want to see if we could gain some additional insight there.

Thanks again.

Nick Colangelo -- President and Chief Executive Officer

Yeah. No worries, Chris. As we talked about on our last call, there were really sort of four things that needed to occur prior to potential NexoBrid approval. One is, the FDA asked for some additional CMC info.

So we're obviously in the process with MediWound, providing that additional CMC information and integrating it into a revised CMC module for use in the resubmission. So that entails work of kind of generating the data, putting it into a package and so on. And so that work has been ongoing and continues. The inspection issue related to CMC issues that FDA restrictions at the time, we believe those are reviewed and that they're now conducting CMC spec inspections in Israel and Taiwan.

And that's something we'll discuss with the FDA upon resubmission. It's a little premature at this point. But we do know that, that those inspections outside the U.S. are now occurring.

The FDA also referenced observations on their GMC, GCP inspections. And so we're in the process of reviewing additional details at study sites to respond to the FDA's questions. And then finally, a routine safety update is being or will be put in place prior to their end as part of the resubmission. So those four elements are all moving forward.

Again had a productive meeting with the FDA agreement on how we were going to plan to respond to their questions. And so now that work is being done and completed and then will be assembled into resubmission package and submitted at this point, our anticipation is by mid-year.

Operator

And we have no other questions in queue at this time. I would like to turn it over to management for closing remarks.

Nick Colangelo -- President and Chief Executive Officer

OK. Well, just wanted to say thanks to everybody for your questions and your continued interest in the company overall. And despite the COVID challenges, the company continues to execute well throughout the year. We expect another as we mentioned, year of significant top-line revenue growth, margin expansion, operating cash flow, driven by both of these high growth franchises.

So given our strong financial profile, portfolio of innovative products in large addressable markets, we believe the company is really well positioned for sustained long-term growth. So thanks again for your questions and have a great day.

Operator

[Operator signoff]

Duration: 54 minutes

Call participants:

Eric Burns -- Head of Financial Planning and Analysis and Investor Relations

Nick Colangelo -- President and Chief Executive Officer

Joe Mara -- Chief Financial Officer

Ryan Zimmerman -- BTIG -- Analyst

Jeffrey Cohen -- Ladenburg Thalmann -- Analyst

Unknown speaker

Sam Bordovsky -- Truist Securities -- Analyst

Chris Cooley -- Stephens Inc. -- Analyst

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