Biodesix (BDSX) Q3 2026 Earnings Call: Revenue Up 10%, Outlook Revised

Biodesix reported year-over-year growth in revenue and diagnostic test volume for Q3 2026, but management said results fell short of its expectations. Lower sales capacity, stronger-than-expected primary care seasonality and delayed development services projects drove the shortfall.

Key Takeaways

• Total revenue increased 10% year over year to $24.0 million, while diagnostic testing revenue rose 16% to $23.0 million.
• Test volume grew 24% to approximately 19,400, but average revenue per test declined 6% due to a higher proportion of Nodify CDT tests.
• Gross margin remained at 81%, marking the sixth consecutive quarter above 80%. Adjusted EBITDA loss improved 16% to $3.9 million.
• The sales organization averaged 101 representatives during the quarter, below management’s plan. Biodesix has since increased the team to approximately 110 and expects to exit 2026 with about 115 representatives.
• Management revised its full-year 2026 revenue outlook to $101 million-$103 million, with the midpoint representing approximately 15% growth over 2025.
• Development services revenue declined to $1.0 million as customers delayed project starts, although contracted business increased sequentially to $8.7 million.

Key Financial Data

Business and Operating Performance

Diagnostic testing remained the primary growth driver. Primary care represented approximately 15% of test volume, consistent with the previous quarter. Physician retention remained strong, but test volume per physician was affected by seasonal patient flows, physician schedules and practice patterns.

Commercial capacity was the largest constraint. Turnover was higher than anticipated, particularly in newer primary care territories, while hiring did not keep pace with attrition and planned expansion. Management said October produced the strongest new physician acquisition of 2026, although newly hired representatives require training before contributing fully.

Biodesix also highlighted the American College of Chest Physicians’ new framework for biomarker-guided lung nodule management. The framework identifies validated biomarker testing as part of standardized risk stratification. Two major West Coast institutions have begun implementing system-wide care pathways incorporating Nodify Lung testing.

The company is developing a radiomics-based lung nodule risk assessment test with Vanderbilt University and Vanderbilt Health, with commercialization anticipated in 2028. It is also advancing tumor-informed and tumor-naive minimal residual disease assays with Bio-Rad Laboratories and Thermo Fisher Scientific, respectively.

Development services revenue was affected by delayed project starts. The company ended the quarter with $8.7 million under contract. Biodesix also added the GeneStrat ESR1 ddPCR test to its CLIA-certified, New York State CLEP-approved laboratory offering.

Management Guidance

Management now expects full-year 2026 revenue of $101 million-$103 million. The midpoint represents approximately 15% growth over 2025. The outlook incorporates Q3 results, the timing of sales hiring and training, and expected development services execution and revenue recognition.

Biodesix continues to expect a full-year gross margin of approximately 80% and further progress toward profitability.

For Q4, management expects development services revenue to remain near $1 million, implying a sequential increase in lung diagnostic revenue. Management also indicated that several delayed development projects are likely to move into 2027 and said a prudent 2027 assumption would place development services at approximately 7%-8% of total revenue.

Risks and Watchpoints

• Sales force turnover and slower hiring reduced the company’s ability to acquire new ordering physicians.
• New representatives require onboarding and training, creating a delay between hiring and revenue contribution.
• Primary care ordering patterns showed greater seasonality than management had expected.
• Development services revenue remains dependent on customer-controlled study starts and sample shipments, which can shift revenue between quarters.
• A sustained mix shift toward Nodify CDT is expected to keep average revenue per test closer to Q2 and Q3 levels rather than the Q1 mix.
• Higher fuel costs increased the expense of shipping test kits to Biodesix laboratories.

Analyst Q&A Highlights

Management identified lower field sales capacity as the largest factor behind the quarterly shortfall, with primary care seasonality also having a meaningful effect. Biodesix expects to resume a hiring cadence of approximately six to eight sales representatives per quarter.

On Q4 comparisons, management noted that the prior-year quarter included slightly more than $1 million of collections from older claims. Excluding those collections, the midpoint of the current outlook implies approximately 2% year-over-year diagnostic revenue growth.

Management said adoption of Nodify CDT for smaller lung nodules remained steady during Q3 after increasing in Q2. The resulting test mix is expected to represent the new operating pattern rather than reverting to the mix seen before the supporting data were published.

Regarding health system integration, management said enterprise-level adoption can streamline physician education, EMR connectivity, test-result delivery and blood collection. However, implementation requires coordination among administrators, clinicians and workflow systems and may take time to generate scalable volume.

Full Earnings Call Transcript

Complete Earnings Call Transcript

Management Remarks

Operator

[Operator Instructions] Be advised that today's conference is being recorded. I would now like to hand the conference over to your speaker today, Chris Brinzey, Investor Relations. Sir, please go ahead.

Christopher Brinzey

Thank you, operator, and good afternoon, everyone. Today, Biodesix released results from the third quarter of 2026. Leading the call today will be Scott Hutton, Chief Executive Officer. He is joined by Robin Harper-Cowie, Chief Financial Officer. An audio recording of today's call and the press release announcement with the quarterly results can be found in the Investor Relations section of the company's website at biodesix.com. As today's call includes forward-looking statements, we encourage you to review the statements contained in today's press release and the risks and uncertainties described in our SEC filings, which identify certain factors that may cause the company's actual events, performance, and results to differ materially from those contained in the forward-looking statements made on today's webcast.

In addition, we will discuss non-GAAP financial measures on this call. Descriptions of these non-GAAP financial measures and reconciliations of GAAP to non-GAAP financial measures are included in today's press release. I would now like to turn the call over to Scott Hutton, Chief Executive Officer. Scott?

Scott Hutton

Thank you, Chris. And thank you all for joining us today.

Biodesix continued to make meaningful progress in the third quarter, with total revenue growing 10%, diagnostic testing revenue increasing 16%, test volumes growing 24%, and gross margin remaining strong at 81%. While we are proud of that growth, our results did not meet our expectations. The shortfall was driven by 3 factors: fewer contributing sales representatives than planned, greater than anticipated seasonality in primary care, and customer-delayed start of several development services projects. The important point is that these were execution and timing challenges, not changes in demand, clinical utility, competitive position, or the size of the opportunity in front of us. We understand what drove the quarter, we've already taken action, and we entered the fourth quarter with improved commercial capacity and a clear focus on execution. Today, I will discuss both the drivers of our quarterly performance and the strategic and clinical progress that continue to strengthen our confidence in the future.

During the quarter, we strengthened our long-term leadership position in lung diagnostics through 3 developments. First, the American College of Chest Physicians, or CHEST, introduced a framework for biomarker-guided lung nodule management. Second, we expanded into multimodal digital diagnostics. And third, we accelerated development of complementary MRD programs. These achievements reinforce our belief that Biodesix is uniquely positioned at the intersection of diagnostics, imaging, molecular diagnostics, and artificial intelligence. While we have work to do, our opportunity has never been clearer, and our conviction has never been stronger. Starting with diagnostic testing, we delivered approximately 19,400 tests, our second-highest quarterly volume, and a 24% increase over the third quarter of 2025. Primary care represented approximately 15% of total test volumes, which was consistent with last quarter, and we continued to see strong retention among our base of ordering physicians.

However, test volume per physician was affected by greater than anticipated seasonality, particularly in primary care. This is our first full year executing a focused primary care strategy. As we continue to expand the market, we're gaining a deeper understanding of how seasonal patient flow, physician schedules, practice patterns, and the availability of lung nodule patients influence ordering behavior throughout the year. These insights are important because they strengthen our ability to forecast demand, allocate resources, and execute more effectively. Importantly, what we saw was not a reduction in physician adoption, retention, or interest in our test. It was a matter of timing and utilization patterns within a growing primary care business. We've incorporated these learnings into our forecasting and commercial planning, and they're already shaping how we approach execution going forward.

During the quarter, we averaged 101 sales representatives in the field, below both our expectations for third quarter and our second quarter average. As a result, a greater portion of our commercial effort was focused on maintaining existing accounts, reducing our capacity to acquire new ordering physicians. 2 factors contributed to the lower headcount. First, turnover was higher than anticipated, particularly within our newer primary care territories. Second, our hiring pace did not keep up with both attrition and our planned growth during the quarter. We moved quickly to address both issues, focusing on stabilizing territories, supporting existing customers, and accelerating hiring and onboarding. Our expansion into primary care has also given us valuable insights into the unique workflow, support, and development needs of these representatives, and we are applying those lessons to how we recruit, train, manage, and support our commercial team.

As we've said previously, the majority of our growth investments are concentrated in primary care. The experience of this year has made us a stronger commercial organization, and we believe the actions we have taken position us to improve execution, expand physician adoption, and capture the opportunity ahead. We now have approximately 110 sales representatives in the field focused on new physician acquisition and growth within existing accounts. We plan to exit the year with approximately 115 representatives, providing increased commercial capacity as we begin 2027. Early fourth quarter trends are encouraging. We're seeing accelerating new physician acquisition, continued growth across our established customer base, and broader physician engagement. In fact, October was our strongest month of new physician acquisitions this year, reinforcing our belief that the actions we have taken are already translating into improved commercial execution.

In parallel, we are advancing digital ordering, EMR integrations, clinical data publications, and health system integrations to make routine ordering easier for clinicians and less dependent on high-touch sales activities. At the same time, we strengthened our leadership position in lung diagnostics through several important milestones. Most notably, CHEST recently announced a new lung nodule management framework that will support broader health system integration of our testing. The framework provides practical guidance for building comprehensive lung nodule programs and identifies validated biomarker testing as a core component of standardized risk stratification. Just as importantly, the framework represents meaningful recognition of the role validated biomarkers can play in improving lung nodule management and supports the growing body of evidence behind tests such as Nodify XL2 and Nodify CDT. At CHEST in October, investigators presented real-world evidence from independent physician groups along with analyses from the CLARIFY study involving more than 2,000 patients. This data evaluated clinical utility, patient follow-up, and the integration of biomarker testing with PET imaging, further strengthening the evidence supporting the use of Nodify testing in lung nodule management programs.

More importantly, we are beginning to see the evidence translate into health system integrations. Increasingly, leading institutions are implementing enterprise-wide lung nodule management pathways rather than relying on physician-by-physician adoption. For example, a major integrated health system on the West Coast has begun implementing a protocolized lung nodule management program, which incorporates Nodify Lung testing within both pulmonologists and primary care physicians. At the same time, one of the nation's premier academic medical centers in the same region has begun implementing a similar care pathway that incorporates Nodify testing as part of a standardized approach to lung nodule evaluation. These implementations are important because they demonstrate how our tests can become embedded within a system-wide clinical workflow rather than depending solely on individual physician adoption. We believe this approach has the potential to improve consistency of care, expand patient access to evidence-based risk assessment, and create a more scalable path for growth. Importantly, enterprise-level integrations require a deliberate rollout.

Establishing care pathways, aligning clinical stakeholders, training physicians, and integrating software workflows is a multi-step process. While implementation takes time, these early wins strongly validate our strategy and represent the type of integrations that can create durable, scalable volume growth over time. As we work to expand adoption of our current tests, we're also building the next generation of lung diagnostics. Our recently announced digital diagnostics initiative begins with a radiomics-based lung nodule risk assessment test being developed in collaboration with Vanderbilt University and Vanderbilt Health. Designed to complement the Nodify Lung portfolio, we anticipate commercializing the test in 2028. This initiative extends Biodesix beyond blood-based diagnostics and advances our vision of integrating imaging, molecular diagnostics, and artificial intelligence into a more comprehensive approach to lung disease management. We believe the future of lung diagnostics will not be defined by a single technology, but by the intelligent integration of imaging, biomarkers, clinical data, and artificial intelligence.

This multimodal approach can improve clinical decision-making, strengthen patient care, and create new opportunities for innovation across pulmonary medicine. Our digital diagnostic strategy positions Biodesix at the center of this transformation. We recently provided additional detail on our 2 complementary approaches to MRD testing, which we are developing with leading collaborators from industry and academia. Our tumor-informed assay, developed with Bio-Rad Laboratories, combines our Diagnostic Cortex bioinformatics platform with droplet digital PCR technology to track patient-specific variants with parts-per-million sensitivity. Our tumor-naive assay, developed with Thermo Fisher Scientific, detects methylated ctDNA using rapid NGS on the GeneXus platform and extends monitoring to patients without access to usable tumor tissue. Together, these programs are designed to address a broader range of patients, clinical settings, and physician needs. Importantly, these assays are being built on platforms with global reach.

Through our collaborations, we have the opportunity to participate in the growth of the MRD market well beyond the limits of a traditional centralized laboratory model, expanding access for laboratories, clinicians, and patients around the world. We will present data from both programs during a dedicated corporate workshop and across multiple presentations at next week's AMP meeting in Seattle. Turning to development services, third quarter revenue was approximately $1 million compared to $1.9 million a year ago. As we have discussed previously, project initiation is driven by the customer and can shift between quarters. Our development service business continues to create value for our partners and for patients, and demand remains strong. We exited the quarter with $8.7 million under contract, an increase over the prior quarter, and a growing interest in our offering. One example, and a recent addition to our offering, is the GeneStrat ESR1 ddPCR test, which we developed in collaboration with Bio-Rad and recently brought into our CLIA-certified New York State CLEP-approved laboratory.

The test uses ultra-sensitive droplet digital PCR technology to detect ESR1 mutations associated with treatment resistance in patients with metastatic breast cancer. In a blinded comparison conducted with investigators at Memorial Sloan Kettering Cancer Center, preliminary results published in the Journal of Liquid Biopsy demonstrated 100% concordance with validated reference NGS assays. The full clinical study will be presented at the San Antonio Breast Cancer Conference in December. While development services revenue can vary from quarter to quarter based on customer project timing, the underlying demand for our capabilities remains strong. More importantly, these collaborations reinforce our position as a trusted development partner and demonstrate how Biodesix can create value beyond our core diagnostic testing. In summary, our immediate focus is restoring commercial momentum, improving execution, and increasing dollars under contract for our development services, while continuing to advance the clinical evidence, strategic capabilities, and partnerships that we believe will support durable long-term growth. The opportunity in front of us remains substantial, and we believe Biodesix is better positioned today than ever before. With that, I will turn the call over to Robin to review our financial performance and outlook. Robin?

Robin Cowie

Thank you, Scott. And good afternoon, everyone. Total revenue for the third quarter was $24.0 million, an increase of 10% compared with $21.8 million in the prior year period. Diagnostic testing revenue was $23.0 million, an increase of 16% year-over-year. Test volumes were approximately 19,400, an increase of 24%. Average revenue per test decreased by 6% year-over-year, driven by a shift in the mix of tests delivered with a higher proportion of Nodify CDT tests delivered. This is a continuing trend that began in the second quarter, partially offset by improvements in reimbursement coverage for both Nodify XL2 and Nodify CDT.

Improvements in Medicare Advantage and other payer collections that drove the positive trends in average revenue per test in the third quarter of last year have continued. Development services revenue was $1.0 million, compared with $1.9 million in the prior year period. Gross margin was 81%, consistent with the prior year period, and our 6th quarter above 80%. Gross margins were supported by higher year-over-year diagnostic testing volumes and continued optimization of laboratory workflows, resulting in lower costs per test. Gross margins were partially offset by higher costs of shipping test kits to our laboratories due to increases in fuel costs across the country. Despite these pricing pressures, we again delivered margins higher than 80%.

Operating expenses, excluding direct costs and expenses, were $25.5 million, an increase of 3% over the prior year period, and a 7% sequential decrease from $27.4 million in the second quarter. The sequential decrease reflects our focus on spending, cost containment, and operating discipline along with lower sales headcount. We continue to balance investments in revenue growth with the objective of improving profitability and capital efficiency. Net loss for the quarter was $8.0 million, an improvement of 8% compared with the prior year period. Adjusted EBITDA was a loss of $3.9 million, a 16% improvement compared with the third quarter of 2025. We ended the quarter with $28.4 million in cash and cash equivalents, a decrease of $1.6 million from June 30, 2026. The change in cash included $6.3 million of net proceeds from our at-the-market program.

Turning to our outlook for the full year 2026, we now expect total revenue of $101 million to $103 million, with the midpoint representing approximately 15% growth over 2025. We continue to expect gross margins of approximately 80% and continued progress towards profitability. The revised outlook incorporates our third quarter results, the timing of sales team hiring and training, and expected development services contract execution and revenue recognition. With that, I will turn the call back to Scott for closing remarks. Scott?

Scott Hutton

Thank you, Robin. We delivered growth in the third quarter, but our results fell short of our expectations. We have already taken corrective action. Underlying demand for our tests remains strong as demonstrated by expanding health system integrations and continued physician adoption. Greater than anticipated seasonality in primary care, reduced commercial capacity, and development services project timing affected our performance during the quarter, and we have taken concrete steps to address each of those factors. The shortfall this quarter was largely a matter of execution and timing, not a change in demand, clinical utility, or market opportunity. At the same time, the clinical and strategic progress we discussed today reinforces our confidence in the long-term opportunity ahead. Our immediate priorities are clear: continue strengthening commercial execution, accelerate new physician acquisition, deepen utilization within existing accounts, and increase development services contracts. We are also applying what we have learned about primary care ordering patterns and seasonality to improve forecasting, planning, and execution.

Our objective is straightforward: translate demand into consistent growth while building a stronger company for the long term. I want to thank the entire Biodesix team for their continued focus, resilience, and unwavering commitment to patients. Their efforts are what continue to drive our progress and position us for future success. I would also like to remind everyone that November is Lung Cancer Awareness Month, a time dedicated to increasing awareness, advancing education, and reinforcing the importance of early detection. The work our team does every day helps clinicians identify and manage patients earlier when interventions can have the greatest impact. Operator, we're now ready to take questions.

Operator

[Operator Instructions] Our first question will come from the line of Thomas Flaten with Lake Street Capital Markets. Please go ahead.

Question-and-Answer Session

Thomas Flaten

Scott, just on the sales rep hiring, so 2 things. With respect to the learnings on the higher turnover on the PCP side, is that just learning how to hire the right people? Was there poaching? I'm just curious what was happening there because, you know, you had your second quarter call August 5, so July, it seems none of this was occurring. Can you just flesh that out a little deeper, please?

Scott Hutton

Yes, thank you, Thomas. It was a mix of all of the above. So yes, we continue to learn about the target hiring profile, similar to the learnings we had in pulmonology that began back in 2019 to 2020. And so as you can imagine, we've refined that over time and really have dialed that in on the pulmonology side. It's nuanced and there were some differences in learnings that we've now applied. So, a higher level of confidence than ever before that we're out recruiting those individuals that we think will be able to hit the ground running and have great success. Yes, we did see a couple of key individuals that were targeted by 1 to 2 diagnostic companies. You know, it's always disappointing to see that when it occurs, but we've stated before our goal is to build the best diagnostic sales team out there with the brightest, most talented professionals.

As we do so, others are going to try to take them from us. And so, disappointing to see those individuals depart, but I'm very excited about the individuals we brought in to replace them. And not only is it the next person up mentality, we're going to continue to get better.

Thomas Flaten

Got it. And then just 1 quick one for Robin on the guide. So, I mean, depending on exactly how you do the math, it implies kind of flattish, maybe slightly up diagnostic testing volume. Any commentary more on how we should think about how the revenue breaks out in the fourth quarter?

Robin Cowie

Yes, we're anticipating that the delays in project timing and development services continues and so anticipating that we will see similar biopharma level. So that would imply a step up in the lung diagnostic revenues over third quarter as we're building out and have more feet on the street this quarter than last.

Thomas Flaten

Got it. Appreciate that. Thank you.

Robin Cowie

Thank you, Thomas.

Operator

Our next question will come from the line of Dan Brennan with TD Cowen. Please go ahead.

Unknown Speaker

This is Pradeep for Dan. So, big picture in 2027, between the primary care strategy, CHEST framework, continued sales force expansion, and the potential increase in overall lung screening given blood-based testing, there are now several different drivers of faster core lung growth. What do you see as the biggest growth driver in 2027, and could these lead to core lung growth acceleration next year, next 2 to 3 years?

Scott Hutton

Yes. Yes, great question, Pradeep. Thank you. Yes, as we look at the overall lung cancer continuum of care, as you referenced, we're big fans and supporters of the numerous companies that have invested in single cancer or multi-cancer early detection tests that function as screeners. What we do know is the majority of patients today that are seen by pulmonologists are found through incidental findings, not through screening programs. So if we can increase participation in screening programs from those patients eligible, we're confident that we're going to have a significant increase in the TAM. And so for us, that is a big, big driver. We believe that we can continue to grow and service the market as it exists today in the absence of those tests being commercialized or reimbursed. And so for us, the biggest drivers remain continuing to grow and scale the sales force so that we have the representative sales team members in the field to support the ongoing need and growth of our business. And we're going to continue to push towards publishing additional data.

We have felt that the best way to increase the likelihood of guideline inclusion is continue to publish and present exceptionally strong data. So we do want to highlight that within pulmonology, the American College of Chest Physicians, or CHEST, is the largest society and that's who provides the guidelines for pulmonologists and they still have not updated their guidelines in nearly 13 years. And so for us, we feel like we've put ourselves in a great position to be included when they do make that update. Right now, the work that was done recently at CHEST to create the worksheet for nodule management, we think is a good indication and a great first step. Hopefully that's helpful, Pradeep.

Unknown Speaker

Yes. Yes, very helpful. Thank you. As a follow-up, you saw strong volume growth in Q2 driven in part by adoption in smaller nodules. How does that trend continue with small nodule progress in Q3? And are you continuing to see physicians broaden Nodify into these smaller nodules?

Robin Cowie

Yes, great question. You're exactly right. Following publication in late first quarter, we saw an increase in the use in particularly Nodify CDT in the small nodules. That drove a mix shift in the test volumes for us in the quarter. That's continued and that sort of the use in small nodules has been fairly steady across the quarters. So we saw a very similar mix in third quarter as we did in second. We are seeing more physicians starting to use CDT in the smaller nodules as well. Just a handful of months post that publication, we're very pleased with the adoption.

Unknown Speaker

Thank you.

Operator

[Operator Instructions] Our next question is coming from the line of Max Masucci with Roth Capital Partners. Please go ahead.

Unknown Speaker

This is Kevin Han on for Max. Maybe just going into initially on the shortfall in the quarter, how much of that was driven more by the seasonality that you mentioned or more by the sales productivity that you saw?

Scott Hutton

Yes, great question, Kevin. Thank you. First and foremost, the greatest impact was really feet on the street. And so as we fell behind on the targeted goal in terms of number of sales reps, that limits our ability to grow. It also causes the sales reps that we have in those territories to move more into a maintenance mode. And so we didn't bring on the appropriate number of new ordering physicians. So those 2 things created significant headwind for us to overcome. But the seasonality was meaningful. And so, you know, we were excited to see that the base ordering physicians remained intact, but the volume that each ordered was less than what we had seen.

And so, again, first full year in primary care, we had made some assumptions on what that seasonality would look like. We've gained additional insights. We'll get better at our forecasting now that we've got that experience. But that was a meaningful impact also.

Unknown Speaker

Thank you, Scott. That's very helpful. Then maybe just going into the CHEST framework. You know, I know it's a little bit early, but maybe like how have your conversations with health systems that maybe haven't established a framework yet evolved? Are you kind of getting any early interest there?

Scott Hutton

Yes. Yes, it's a great question. You know, that framework was rolled out at CHEST. The first full day of the meeting, there was a learning theater session, and it was a packed house. And so for us, as we look at that, that definitely demonstrates that there's a need and an interest. And so subsequently, we've had a number of dialogues with both new physicians to us, new institutions to us, and some that we had been working with. The way we look at this is because it was a CHEST-sponsored and initiated effort, in the absence of guidelines, this is all that a CHEST physician has to go off of. And so it's only been a couple of days and weeks here since the CHEST meeting.

So our sales team is out there asking questions. We're providing resources. We've seen significant progress. So we think it's meaningful. We think it's impactful. I think you heard it in really what we just stated and disclosed. It really helps a new onboarding practice have a roadmap. In the absence of that roadmap, they're probably inefficient in how they onboard, how they learn. And if we can consolidate so that that roadmap is a best in practice scenario, or guideline, then we can onboard accounts quicker.

We think that in so doing, it'll also increase their reorder rates and get them to a more substantial ordering volume. So it's significant, and we did reference the 2 major institutions on the West Coast, and we've seen them not really even adopt this, but take a best-in-class approach which mirrors this. So definitely a huge opportunity for us to view this one as a tailwind.

Unknown Speaker

Thank you, guys.

Operator

Our next question will come from the line of Bill Bonello with Craig-Hallum. Please go ahead.

William Bonello

Just a couple of questions. I guess I first, I'd just like to, you know, circle back again to that guidance discussion. I mean, if I followed your math right, and I assume about $1 million again in Q4 for development services. At the midpoint of the guide, I think I get, you know, like $24.6 million or something for lung diagnostic revenue, which would still be down on a year-over-year basis. So up sequentially, but I guess I'm not understanding what in the factors that you've been describing, what would drive a year-over-year decline in revenue? I get why maybe revenue wouldn't have grown as robustly as you had hoped, but why would it actually be going down?

Robin Cowie

Thank you for asking that question, Bill. One of the things that I want to make sure to call out is that the fourth quarter comp of last year included just over $1 million in back claims collections from older claims. If you take that out and so normalize the fourth quarter, it does imply, the midpoint of the range implies a 2% growth year-over-year, which is obviously slower than where we wanted it to be, but is growth over that number.

William Bonello

Okay, that's helpful. And even that, maybe just following up on that, again, 2%. The kinds of things I heard you describing weren't the kinds of things that sort of take growth from sort of 20% plus down to 2%. They, again, were the kinds of things that maybe seemed like they'd knock it down a little bit more. Is there anything else, you know, we're missing? Because it sounds like you're saying no change in demand, you had a record October, you're continuing to add physicians, I thought you said the physicians were doing more testing, you know, the tests per physician was increasing in October. I just feel like I'm missing something here.

Scott Hutton

Yes, and maybe a point of clarification. We did not state we had a record October. We stated we had the strongest new physician acquisition, so growth into those new physicians. And a reminder that we've stated in the past that even though we're aspiring to hire the best and the brightest, as we do so, they still have to go through an onboarding and training process, and that can take time before they can actually be in the field positively contributing. That's why it's really important for us to get them into the field and through training as quick as possible and as early as possible in the quarter. So there's a ramp to their contributions. And so think of it in terms of a recovery and a rebound. Everything is pointing in the right direction.

As you said, we're very excited about the performance we saw over the past few weeks, and we feel confident that that'll continue and maintain, but there is a cadence of events that build upon one another.

William Bonello

Okay, and then just more positively, you talked about a major health system incorporating Nodify Lung into its nodule program. Can you just give a little bit more color on that? Like what specifically does that mean? Are they, you know, suggesting to their primary care physicians that, you know, any patient with a nodule that falls into the category that would be appropriate for Nodify Lung is being screened that way? Maybe just whatever you can tell us about it.

Scott Hutton

Yes, yes, thank you. The way that I would think about this is based upon the data that we've published and presented over the years, we finally were able to have a strategic discussion with them at the administrative level. So administration bought into it. They understand the need. They understand the volume of patients, and so as they endorsed it and sponsored it, we were able to partner and collaborate with them to ensure that we're educating and onboarding the right group of physicians. Their leadership brought them all together. And so through that, we were able to train and educate all primary care physicians and nurses so that the entire staff understood. We worked with them again at an administrative level to work on workflow integration, talking through things like test result delivery, did they want it in paper, did they want it through a portal, blood draw, you know, the phlebotomy services. So, all of those things that we helped coordinate were done on the front end and not done in an individual one-off basis.

It was done system-wide. And so, you know, when our sales reps go out and they're selling the test, usually they're selling to 1 individual physician and it builds from kind of a bottom-up or ground-up. This should be viewed as top-down where you have endorsement and support from administration, and then they help to lead and facilitate that education and workflow integration. So some of the things that it should mean is do those accounts order more? We'd like to think so, we'll prove that out in time. You've got direct linkage into their EMRs, so you can help track and pull the appropriate patients more efficiently and effectively. Blood draw capabilities, whether it's done on-site or with a mobile phlebotomy service, all of that is coordinated and planned, so you're much more efficient and effective as you introduce Nodify testing. Is that helpful, Bill?

William Bonello

Yes. Yes, I appreciate it. Thank you very much.

Scott Hutton

Yep. Thank you, Bill.

Operator

Our next question will come from the line of Kyle Mikson with Canaccord Genuity. Please go ahead.

Alexander Vukasin

Hi, this is Alex Vukasin on for Kyle Mikson. So another solid quarter of test volume growth, yeah, a bit below our estimate and the Street. Could you just elaborate a bit on the relatively more modest test volume growth in the quarter with respect to the seasonality and issues onboarding new physicians? I know you've probably talked about this fairly extensively earlier on the call. Just trying to figure out and confirm if some of these aspects are perhaps more transitory in nature, and some of this could be alleviated by the hiring that you discussed. Thank you.

Robin Cowie

Yes, thanks Alex. Yes, it was really primarily driven by the number of feet on the street, being out there and able to call on new physicians. We had 101 in the quarter calling on about 30,000 physicians. It was really under where we wanted to be. So the folks that were still in their territories were working on calling on and supporting the base physician business. We do think that's transitory. We've hired and we had, we're at 110, we expect to be at 115 by the end of the year and continue to focus on that hiring and training and getting those folks up to speed quickly and out in the field calling on physicians. The seasonality caught us a bit by surprise, primarily in the general practice or primary care area. As you know, we started calling in primary care last year.

And so we're just starting to get enough volumes and enough physicians to be able to see a trend in what happens in their practices with patient workflow, vacations, things like that, which does look to be a little different than what we see in pulmonology. We are seeing rebounds in the seasonality impact here in October in both groups, in both pulmonology and primary care. We did add our largest number of new physicians in October, so that's a good sign as well. And we're incorporating all of these learnings into our forecasting for the future.

Alexander Vukasin

Great, that's really helpful. Just building on that question, I was thinking about hiring going forward. Obviously, there was some catch-up recently. How do you think about 2027 cadence for hiring? Could that return back to prior levels once you've, you know, fully achieved this catch-up? Thanks.

Scott Hutton

It's a great question. Yes, what we've demonstrated over time is that hiring approximately 6 to 8 on a quarterly basis for us ensures that we're bringing in the best and the brightest. We're spending the appropriate amount of time to ensure that they understand the products inside and out and all the clinical data that support it. And then it allows us to put them in the field, and it's a regular cadence that has worked well for us. Yes, we feel confident that we can get back to and maintain that in the foreseeable future. And as Robin said, I can state that we're returning back to that already. We just had a sales training class that was in last week and moved out to the field this week. So that is a cadence that we've demonstrated works well for us.

Obviously, through these learnings and these experiences, we're going to be better prepared to flex and increase the size of those classes if and when something challenging would present in the future again. And so we'll continue to get better. But right now, 6 to 8 is what we're looking at, and we'll keep you updated as we progress through this year and start 2027.

Alexander Vukasin

Got it. Thank you.

Scott Hutton

Thanks, Alex.

Operator

Our next question comes from the line of Yi Chen with H.C. Wainwright. Please go ahead.

Yi Chen

for Yi. A couple quick follow-up questions from earlier. Looking at development services, you mentioned the delays may be ongoing. How much of the third quarter business has kind of flipped into fourth quarter versus onwards into 2027? And looking forward, are there big picture assumptions we should kind of shift to better match how cadence is really flowing in that business?

Robin Cowie

Yes, hi Katie. Thanks for your questions. We are actively tracking multiple projects and various study start dates and sample shipments. That really drives when we are able to execute on those projects and recognize the revenue. As I mentioned earlier, we're anticipating that fourth quarter will look very similar, say around $1 million for development services in the fourth quarter. So many of those projects we're anticipating that they slip into 2027. For 2027, we think it's prudent to be slightly conservative on the estimates for development services and are anticipating that would be probably in the 7% to 8% of total revenue range. We, depending on the year, average between 7% and 10% and think that 7% to 8% is a good target for 2027.

Yi Chen

Another quick follow-up was on the revenue per test. We saw a shift in the mix of the different tests. Do you think this mix is the new normal, or do you think it will shift backwards towards what we were seeing more in Q1?

Robin Cowie

No, I think this is more towards the new normal. As physicians have started ordering in the smaller nodules. This is where they are usually watching and waiting using CT surveillance, but finding those cancers early is really critical. That's where CDT alone plays an important part, and that's where we see the mix shift. We saw some pretty rapid adoption in the second quarter in that area and that ratio has pretty much continued. We saw a little bit of a change, but not near what we saw in the second quarter. So we do anticipate that it remains more like you saw in the third, maybe second quarter, versus going back to the ratios that we saw before that the data came out in small nodules.

Yi Chen

Perfect.

Operator

Ladies and gentlemen, this will conclude today's question and answer session. This will also conclude today's conference call. Thank you for participating, and you may now disconnect. Everyone, have a great day.

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