What Ray Cohen Knows About Medtech IPO Readiness That 15 Public Device Companies Missed

Two bankers have told you the medtech IPO window is open again. Your board has started using the word optionality. Six device companies went public last year after a three-year drought, and someone has put a slide in front of you suggesting you could be next.

But nobody in that room is asking the harder question, which is whether the company survives what happens after the listing.

A medtech IPO is a commitment to beat published expectations every quarter, in public, for as long as you stay public. Most companies that clear the listing bar cannot hold that line.

Key Takeaways

• Ray Cohen keeps a list of 15 medical device companies that went public between 2018 and 2021 and are not worth the capital they raised
• Axonics beat its numbers for 20 consecutive commercial quarters, with 14 analysts covering the stock, before Boston Scientific paid $3.7 billion
• Axonics priced its own IPO in October 2018, eleven months before its first FDA approval and before it had a dollar of revenue
• Institutional investors price a medtech IPO against a public comparable they already own, which makes your comparable a category decision
• Six device companies went public in 2025 after a three-year drought, which reopens the readiness question rather than settling it
• The work that decides whether a listing succeeds is market engineering, and it happens years before a banker joins the conversation

Watch the full episode on YouTube

What Medtech IPO Readiness Means Beyond Listing Eligibility

Readiness is the ability to survive public-market scrutiny once the listing is behind you. Eligibility asks whether you can go public. Access is about whether the window is open. Readiness asks whether your growth is fast enough and repeatable enough to beat analyst consensus quarter after quarter once you are there.

Almost every article ranking for this term answers the first two questions. They count who listed and debate whether the window is open.

Both are real questions. But they are the banker's questions, and they date within weeks.

The third one is yours, and it stays true regardless of what the market does.

Why 15 Device Companies Went Public and Never Earned Back Their Raise

Between 2018 and 2021, a cohort of medical device companies completed IPOs and then failed to hold the value they raised. These were credible companies with real products and real investors behind them. They cleared every eligibility bar the bankers set and still could not execute once the quarterly clock started.

I interviewed Ray Cohen, founder and CEO of Axonics, on an episode about how he built and sold a $3.7 billion neuromodulation company.

He mentioned a talk he had given recently, where he shared a list of 15 medical device companies. All of them went public in that window. None is worth the capital it raised.

Then he described the aftermath:

The playing field is littered with dead bodies of companies or the walking dead. Many of them are alive but barely. Going public is not ultimately the panacea. You better be growing your damn company fast and you better do it consistently, because the public markets are unforgiving.

The phrase that lands hardest there is "the walking dead." Those companies still trade, still file, and still employ people who show up every Monday.

But they have no currency. They cannot raise on decent terms, they cannot use stock to acquire, and they cannot attract the talent that a rising share price buys. The listing that was supposed to fund the next phase became the thing that capped it.

So the failure mode here is a successful IPO at a company that was not ready for the obligation it created.

How Do Public Markets Judge a Medtech Company After the IPO

Public markets judge you against consensus, not against your internal plan. You issue guidance, sell-side analysts build a number from it, and your stock reprices against that number every quarter. Beating your own budget counts for nothing if you miss what the analysts published.

Axonics is the counter-example, and the numbers are worth stating plainly. Twenty consecutive commercial quarters of beating expectations, with 14 analysts covering the company.

On the same episode, Ray was blunt about the mechanic:

We had 14 analysts covering Axonics. They make predictions about what you've said to them, and then they do their own interpretation. But if you don't beat the analyst consensus, you're dog meat. Your stock's going down.

Twenty quarters is five years. That is the part founders skim past when they read the Axonics acquisition story and see only the $3.7 billion headline.

No single quarter in that run was spectacular. The compounding came from never missing.

And that is a commercial-systems question long before it is a finance question. A company that cannot forecast its own revenue within a tight band has no business publishing guidance to strangers who will punish the variance.

Can a Medtech Company Go Public Without FDA Approval or Revenue

Yes, and Axonics is the reference case. It priced its IPO on the Nasdaq on October 31, 2018, selling 8,000,000 shares at $15.00 for $120 million in gross proceeds. Its first FDA approval arrived in September 2019, roughly eleven months later. The company had no approved product and no product revenue on the day it listed.

Ray flagged how unusual that was:

What was unique about it is it's the first company that anybody can remember that's in devices, not pharma, that was able to go public without FDA approval and without any revenue.

With no approval to evaluate, investors underwrote a market read instead. Four things carried the offering:

• A large indication with patients underserved for years
• A single dominant incumbent to take share from rather than a fragmented field
• Reimbursement that already existed, so nobody had to invent a payment pathway
• A management team that had done this before

Read that list again. Every item on it describes the market rather than the device.

Each one is a statement about whether the market was formed and legible enough for an institution to underwrite. That is market engineering doing the work that a clearance letter usually does.

How to Anchor Your Medtech IPO Story to a Public Comparable

Institutions price what they already understand. The fastest route to a valuation is a public company the fund managers already hold, because the analogy does the explaining for you before you finish your second slide.

Ray made this point from the other direction at the MD&M 2026 keynote he shared with Tom West, describing how he pitched a future listing:

I'm saying, yeah, we're going to take this company public, because all institutional investors in America own this iRhythm stock. They know the story. I show up in a meeting and it's, hey, remember iRhythm? Well, guess what, we're the iRhythm for ambulatory blood pressure monitoring.

By his account at that keynote, iRhythm carried roughly a $900 million annualised revenue line and about a $5.5 billion market cap.

Notice what the comparable is doing. It performs a category placement, and the valuation follows from where it puts you.

You are telling an investor which shelf you belong on. And if no public company occupies the shelf you are claiming, that absence is itself the finding. Your category has not formed yet, which is a far more useful thing to learn in a practice meeting than in a roadshow.

What This Means for Medtech Founders

In my experience working with medtech founders, the IPO conversation starts about two years before the readiness work would have needed to start. The window is open, the bankers are attentive, and the pressure to move is real.

But the variables that decide the outcome were set much earlier.

Across 370-plus episodes of The State of MedTech, the pattern holds. The companies that survive the public markets engineered a legible market before they needed one, closing the traction gap while they still had runway to do it.

The category existed. The buyer already knew why the problem mattered. And revenue was forecastable because demand was pull-driven rather than pushed through by founder effort on every deal.

At MarketCraft, the first question we ask a team considering a listing has nothing to do with bankers or comparables. It is whether they can predict next quarter's revenue within a narrow band, and explain the mechanism that produces it.

If the answer involves the founder personally closing the top three deals, the company is not ready. The product may be excellent. There is still no system for an analyst to underwrite.

FDA clearance is the starting line, not the finish line. A listing is another starting line, and a more expensive one, because the scoreboard updates every 90 days and the people reading it have no loyalty to your mission.

So the work is the same work it always was. Form the category, make the demand repeatable, and get the forecast tight. Do that and the listing becomes an option you control rather than a window you chase. For the broader version of this argument across every exit route, read how to exit your medtech company.

Frequently Asked Questions

How many medtech companies went public in 2025

Roughly six to seven, depending on how medtech is scoped. Life Science Intelligence counts six: Beta Bionics, Kestra Medical Technologies, CapsoVision, Carlsmed, Shoulder Innovations and HeartFlow. RSM cites seven through October 2025 using Bloomberg data. Both figures mark a clear recovery from the three-year drought that preceded them.

Can a medical device company IPO without FDA approval

Yes, though it is rare. Axonics listed on the Nasdaq in October 2018 and received its first FDA approval in September 2019. Investors substituted market evidence for regulatory evidence: a large underserved indication, one dominant incumbent to take share from, existing reimbursement, and a management team with a prior track record.

What revenue does a medtech company need before an IPO

There is no threshold, and companies have listed pre-revenue. The operative question is whether growth is fast and repeatable enough to beat analyst consensus quarter after quarter once you are public. That bar is considerably higher than reaching any particular revenue number, and it is the one most candidates fail.

Is a medtech IPO better than an acquisition

Neither route dominates. An IPO opens access to larger pools of capital and keeps the company independent, at the cost of permanent public scrutiny. An acquisition is faster and cleaner but ends the story. Axonics did both, listing in 2018 and then selling to Boston Scientific for approximately $3.7 billion in 2023.

How long does medtech IPO preparation take

The banking process runs months. Readiness runs years. Forming the category, building commercial execution that repeats without founder heroics, and establishing a credible public comparable all happen well before an underwriter is engaged. Founders who start this work when the window opens have already started too late.

Where to Go From Here

If you're doing this yourself. Run your current raise materials through the Pitch Deck Analyzer. It scores how an institutional reader receives your market conviction, which is the same thing an analyst will test once you are public.

If you want it engineered with you. MarketCraft takes on a small number of medtech teams each quarter, starting with The Market Engineering Audit. It maps whether your category is formed enough to carry a public listing, and what to build first if it is not.

Listen to Ray Cohen's Full Story

Ray Cohen's full conversation with Omar Khateeb is available on The State of MedTech. Watch on YouTube. Subscribe wherever you listen to podcasts.

About Ray Cohen

Ray Cohen is the founder and former CEO of Axonics, the sacral neuromodulation company he took public on the Nasdaq in October 2018 and sold to Boston Scientific for approximately $3.7 billion in 2023. He spent decades in medical devices before founding Axonics and is a regular keynote speaker at industry events including MD&M.

About the Author

Omar Khateeb is the founder of MarketCraft and host of The State of MedTech, the number one podcast in the medtech industry. He works with medtech founders and commercial leaders on market engineering, commercialisation strategy, and revenue growth. Visit marketcraft.ai or subscribe to The State of MedTech for weekly conversations with the people building the future of medical devices.