Predicate Devices

Not Found

Reference Devices

Not Found

AI/ML (Artificial Intelligence / Machine Learning)

No
The summary describes a standard molecular diagnostic test and does not mention any AI or ML components in the device description, intended use, or performance studies.

Therapeutic

No.
The device is a diagnostic test for the detection of SARS-CoV-2 nucleic acid, not a device used for therapy or treatment. Its intended use explicitly states it should not be used to determine any treatments without provider supervision and that negative results should not be used as the sole basis for treatment.

Diagnostic

Yes
The device is described as a "nucleic acid amplification assay" used "for the rapid, qualitative detection of SARS-CoV-2 nucleic acid directly in anterior nasal swab specimens from individuals with signs and symptoms of COVID-19." This function of detecting a pathogen to inform diagnosis clearly falls under the definition of a diagnostic device.

SaMD (Software as a Medical Device)

No

The device description clearly states that the system includes hardware components: the Cue Health Monitoring System (Cue Reader), the Cue COVID-19 Molecular Test Cartridge, and the Cue sample wand. While the Cue Health App is software, it is part of a larger system that includes physical hardware for sample collection and analysis.

IVD (In Vitro Diagnostic)

Yes, this device is an IVD (In Vitro Diagnostic).

Here's why:

Intended Use: The intended use explicitly states it's a "nucleic acid amplification assay for the rapid, qualitative detection of SARS-CoV-2 nucleic acid directly in anterior nasal swab specimens." This describes a test performed in vitro (outside the body) on a biological sample to diagnose a condition.
Device Description: The description details a system that analyzes a biological sample (anterior nasal swab) using a cartridge and reader to produce a test result. This is characteristic of an IVD.
Performance Studies: The document describes clinical studies where the device's performance (sensitivity, specificity, etc.) is evaluated against a comparator method using biological samples. This is a standard process for validating IVDs.
Key Metrics: The inclusion of metrics like Positive Percent Agreement (PPA) and Negative Percent Agreement (NPA) are standard performance indicators for diagnostic tests, including IVDs.

The core function of the device is to analyze a biological sample in vitro to provide diagnostic information about the presence of SARS-CoV-2. This aligns perfectly with the definition of an In Vitro Diagnostic device.

PCCP (Predetermined Change Control Plan) Authorized

N/A

Overview

Intended Use / Indications for Use

The Cue COVID-19 Molecular Test is a nucleic acid amplification assay that is used with the Cue Health Monitoring System (Cue Cartridge Reader) for the rapid, qualitative detection of SARS-CoV-2 nucleic acid directly in anterior nasal swab specimens from individuals with signs and symptoms of COVID-19 (i.e., symptomatic).

A negative test result is presumptive, and it is recommended these results be confirmed by a labbased molecular SARS-CoV-2 assay if necessary for patient management. Negative results do not preclude SARS-CoV-2 infections and should not be used as the sole basis for treatment.

Positive results do not rule out co-infection with other respiratory pathogens.

This test is not a substitute for visits to a healthcare provider or appropriate follow-up and should not be used to determine any treatments without provider supervision.

This test is intended to be sold over-the-counter (OTC) for testing of individuals 18 years of age and older.

Product codes (comma separated list FDA assigned to the subject device)

QWB

Device Description

The device consists of the Cue Health Monitoring System (Cue Reader), the Cue COVID-19 Molecular Test Cartridge, and the Cue sample wand. Users must first download and install the Cue Health App onto their mobile smart device. Users then create an account (first time use) and pair the Cue Reader with the mobile smart device. Multiple profiles can be set up under each user account. The appropriate profile is selected and the user inserts the Cue COVID-19 Molecular Test Cartridge into the Cue Reader. The Cue COVID-19 Molecular Test Cartridge must warm up prior to initiating a run. The user collects an anterior nasal swab sample by swabbing both nares with the Cue sample wand and then inserts the Cue sample wand nasal sample into the port of the Cue COVID-19 Molecular Test Cartridge. The test will start as soon as the Cue Sample Wand is inserted into the Cue COVID-19 Molecular Test Cartridge and is completed in 20 minutes. The Cue Health App will show the Cue COVID-19 Molecular Test result when the test is complete. The result is saved in the Cue Account profile that was selected before the test started.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

anterior nasal swab specimens

Indicated Patient Age Range

18 years of age and older

Intended User / Care Setting

Over-the-counter (OTC), at-home performance.

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

A prospective all-comer study enrolled subjects at 13 sites, from December 2020 - February 2021 and November 2021- February 2022 to evaluate the clinical performance of the Cue COVID-19 Molecular Test in symptomatic individuals. Cue system set-up, sample collection, and testing were completed by each subject in a simulated home environment. Each subject was allowed " minutes to obtain a Cue COVID-19 Molecular Test result, including a retest if needed due to an initial canceled test or invalid result. A nasal swab sample was then collected by a trained operator for comparator testing. A consensus comparator (agreement between at least two FDA Emergency Use Authorized (EUA) molecular tests for SARS-CoV-2) was used for method comparison.

(DICS) One subject was excluded due to a protocol deviation; subjects were excluded due to no available Cue result; Subjects were excluded due to no available comparator result. There were 902 evaluable subjects with (b)(4) 1902) male (0)(4) 1902) female, 000 nonbinary, and with unreported gender. The age of participants ranged from 18 years old to 87 years old, with a mean of 40.9 years. The education level of subjects ranged from high school to post-graduate. Results obtained with the Cue COVID-19 Molecular Test were compared to the results obtained with the consensus comparator to determine clinical performance.

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

Clinical Study:
A prospective all-comer study enrolled 902 evaluable subjects at 13 sites, from December 2020 - February 2021 and November 2021- February 2022. Subjects were symptomatic individuals. Cue system set-up, sample collection, and testing were completed by each subject in a simulated home environment. A nasal swab sample was collected by a trained operator for comparator testing using a consensus comparator (agreement between at least two FDA Emergency Use Authorized (EUA) molecular tests for SARS-CoV-2).
Results:

Positive Percent Agreement (PPA) = 92.9% (130/140) (95% CI: 87.4% - 96.1%)
Negative Percent Agreement (NPA) = 98.7% (752/762) (95% CI: 97.6% - 99.3 %)

Usability and User Comprehension Study:
A usability study was conducted with 95 subjects (ages 18 and older) to assess lay users' execution of Cue Reader set up and Cue COVID-19 Molecular Test workflow. 98% (93/95) successfully completed testing. User comprehension was also assessed via a questionnaire completed by 776 subjects enrolled in the clinical study.

Flex Studies:
A series of experiments were conducted to evaluate the device's operational limits simulating conditions of use outside the intended environment or user errors. These studies included:

Improper Wand Insertion: Verified that incorrect wand insertion leads to canceled tests with appropriate app messages (29/29 tests cancelled for each scenario).
Delay in Testing: Evaluated performance with samples not immediately tested. One false negative result observed for 10 min hold time, mitigated by instructions for immediate testing.
Improper Storage Conditions (opened pouch, sunlight, frozen, refrigerated without acclimation, expired, used cartridges): Assessed stability and system recognition of improper conditions. False positive/negative results observed in some conditions (e.g., open pouch, sunlight, frozen), mitigated by labeling. System successfully cancelled tests for unacclimated/expired/used cartridges.
Functionality of Internal Control: 38/40 tests returned invalid for blank wands, 2 returned negative. Failure mitigated by detailed collection instructions.
Improper Positioning (tilt): Verified that the system prevents testing or cancels tests if tilted beyond specified angles (12/12 successful tilt warnings/cancellations).
Vibrations (x, y, z profiles): One false negative and three false positive results observed across vibration tests, mitigated by warnings not to move the reader during testing.
Atmospheric Pressure (high altitude): 0/30 negative and 30/30 positive samples detected.
Lighting Conditions: All 6 LED combinations accurately called by 3 viewers from 1 meter.
Electrical Power (low battery, power fluctuations): System cancelled tests for low battery, and completed tests successfully during various electrical interferences.
Dropping (cartridge and reader): No false results observed for dropped items.

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Positive Percent Agreement (PPA) = 92.9% (130/140) (95% CI: 87.4% = 96.1%) .
Negative Percent Agreement (NPA) = 98.7% (752/762) (95% CI: 97.6% 99.3 %) .

Predicate Device(s): If the device was cleared using the 510(k) pathway, identify the Predicate Device(s) K/DEN number used to claim substantial equivalence and list them here in a comma separated list exactly as they appear in the text. List the primary predicate first in the list.

Not Found

Reference Device(s): Identify the Reference Device(s) K/DEN number and list them here in a comma separated list exactly as they appear in the text.

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information for the subject device only (e.g. presence / absence, what scope was granted / cleared under the PCCP, any restrictions, etc).

Not Found

Regulation Number and Section

N/A

Summary

0

EVALUATION OF AUTOMATIC CLASS III DESIGNATION FOR Cue COVID-19 Molecular Test DECISION SUMMARY

I Background Information:

A De Novo Number

DEN220028

B Applicant

Cue Health Inc.

C Proprietary and Established Names

Cue COVID-19 Molecular Test

D Regulatory Information

| Product
Code(s) | Classification | Regulation
Section | Panel |
|--------------------|----------------|-----------------------|-------------------|
| QWB | II | 21 CFR 866.3984 | MI - Microbiology |

Submission/Device Overview: II

A Purpose for Submission:

De Novo request for evaluation of automatic class III designation for the Cue COVID-19 Molecular Test.

B Measurand:

SARS-Coronavirus 2 (SARS-CoV-2) nucleic acid

C Type of Test:

Isothermal nucleic acid amplification test

III Indications for Use:

A Indication(s) for Use:

1

The Cue COVID-19 Molecular Test is a nucleic acid amplification assay that is used with the Cue Health Monitoring System (Cue Cartridge Reader) for the rapid, qualitative detection of SARS-CoV-2 nucleic acid directly in anterior nasal swab specimens from individuals with signs and symptoms of COVID-19 (i.e., symptomatic).

A negative test result is presumptive, and it is recommended these results be confirmed by a labbased molecular SARS-CoV-2 assay if necessary for patient management. Negative results do not preclude SARS-CoV-2 infections and should not be used as the sole basis for treatment.

Positive results do not rule out co-infection with other respiratory pathogens.

This test is not a substitute for visits to a healthcare provider or appropriate follow-up and should not be used to determine any treatments without provider supervision.

This test is intended to be sold over-the-counter (OTC) for testing of individuals 18 years of age and older.

B Special Conditions for Use Statement(s):

OTC - Over The Counter

C Special Instrument Requirements:

A mobile smart device with wifi access and the Cue Health Monitoring System (Cue Reader).

IV Device/System Characteristics:

A Device Description:

The device consists of the Cue Health Monitoring System (Cue Reader), the Cue COVID-19 Molecular Test Cartridge, and the Cue sample wand. Users must first download and install the Cue Health App onto their mobile smart device. Users then create an account (first time use) and pair the Cue Reader with the mobile smart device. Multiple profiles can be set up under each user account. The appropriate profile is selected and the user inserts the Cue COVID-19 Molecular Test Cartridge into the Cue Reader. The Cue COVID-19 Molecular Test Cartridge must warm up prior to initiating a run. The user collects an anterior nasal swab sample by swabbing both nares with the Cue sample wand and then inserts the Cue sample wand nasal sample into the port of the Cue COVID-19 Molecular Test Cartridge. The test will start as soon as the Cue Sample Wand is inserted into the Cue COVID-19 Molecular Test Cartridge and is completed in 20 minutes. The Cue Health App will show the Cue COVID-19 Molecular Test result when the test is complete. The result is saved in the Cue Account profile that was selected before the test started.

B Principle of Operation

The Cue COVID-19 Molecular Test Cartridge utilizes isothermal nucleic acid amplification technology for the qualitative detection of SARS-CoV-2 nucleic acids. This test is a molecular nucleic acid amplification test (NAAT) that detects the nucleic acid of SARS-CoV-2 using a molecular amplification reaction. The SARS-CoV-2 target primers amplify a region of the

2

nucleocapsid (N) gene. The SARS-CoV-2 target forward primer is conjugated to an affinity tag. RNase P serves as the internal control. The RNase P forward primer is conjugated to a different affinity tag. Both SARS-CoV-2 target and RNase P reverse primers are conjugated to an enzyme. Both the SARS-CoV-2 target and RNase P probes bind to the middle-region of the target amplicon. Following target amplicons the amplicons are bound to a functionalized electrode (one for SARS-CoV-2 and one fore RNase P) via the affinity tag conjugated to the forward primer. The enzyme-bound to the reverse primer then catalyzes a redox reaction. The current flow from the electrodes provides a semi-quantitative nanoampere measurement that is converted to a positive or negative result (based on a pre-determined cutoff).

The RNase P internal control has been designed to control for presence of human cellular. material in the sample and proper assay execution including sample lysis, inhibition, amplification, and assay reagent function for each critical step. If RNase P is not detected, the Cue COVID-19 Molecular Test will return an "Invalid" result.

When the user inserts the Cue sample wand with anterior nasal sample into the cartridge, the test automatically begins. Heating, mixing, amplification, and detection take place within the cartridge.

C Instrument Description Information

1. Instrument Name: Cue Health Monitoring System (Cue Reader).
1. Specimen Identification: Anterior Nasal Swabs.
1. Specimen Sampling and Handling: Once the sample has been collected, the Cue sample wand is immediately inserted directly into the Cue COVID-19 Molecular Test Cartridge.
1. Calibration: Not Applicable.
1. Quality Control: Internal Control.

V Standards/Guidance Documents Referenced:

Document Number	Title	Publishing Organization
EP17-A2	Evaluation of Detection Capability for Clinical Laboratory
Measurement Procedures, 2nd Edition	CLSI
EP25	Evaluation of Stability of In Vitro Diagnostic Reagents	CLSI
N/A	Content of Premarket Submissions for Software Contained in
Medical Devices	FDA

3

Document Number	Title	Publishing Organization
N/A	Content of Premarket Submissions for Management of
Cybersecurity in Medical Devices	FDA
ISO 10993-1:2018	Biological evaluation of medical devices - Part 1: Evaluation and
testing within a risk management process	ANSI AAMI ISO
ISO 14971:2019	Medical devices - Applications of risk management to medical
devices	ANSI AAMI ISO
IEC 62133:2012	Secondary cells and batteries containing alkaline or other non-acid
electrolytes - Safety requirements for portable sealed secondary
cells, and for batteries made from them, for use in portable
applications	IEC
IEC 60601-1-2:2014	Medical electrical equipment -- Part 1-2: General requirements for
basic safety and essential performance -- Collateral Standard:
Electromagnetic disturbances -- Requirements and tests	ANSI AAMI IEC

VI Performance Characteristics:

A. Analytical Performance

1. Precision:

A precision study was conducted to assess the total variability of the Cue COVID-19 Molecular Test across testing days, operators, and Cue COVID-19 Molecular Test cartridge lots. The testing panel was with inactivated SARS-CoV-2 (isolate USA-WA1/2020) diluted into clinical nasal matrix and then spiked onto Cue sample wands. The testing panel consisted of four members: (1) Negative (no analyte); (2) C20.80 (0.3xLoD); (3) C95 (1xLoD); and (4) C100 (2.5xLoD), Cue COVID-19 Molecular Test cartridge lots were tested by two operators each across twelve non-consecutive days, each running two replicates per day (3 lots × 2 operators/lot × 12 days/operator × 2 replicates/day) for a total of 144 observations per panel member. A total of 60 Cue readers were used in this study. The results are presented in Table 1.

		Percent agreement with expected results (n/N) (95% Confidence Interval)
Lot	Operator	Negative	C20-80	C95	C100
1	Operator 1	100% (24/24) (86 -
100%)	96% (23/24) (79 -
100%)a	92% (22/24) (73 -
99%)	100% (24/24) (86% -
100%)
	Operator 2	96% (23/24) (79 -
100%)b	83% (20/24) (63 -
95%)	100% (24/24) (86 -
100%)	100% (24/24) (86% -
100%)
	Overall	98% (47/48) (89% -
100%)	90% (43/48) (77% -
97%)	96% (46/48) (79% -
100%)	100% (48/48) (93% -
100%)
2	Operator 1	96% (23/24) (79 -
100%)	96% (23/24) (79 -
100%)	96% (23/24) (79 -
100%)c	100% (24/24) (86% -
100%)
	Operator 2	100% (24/24) (86 -
100%)	92% (22/24) (73 -
99%)	100% (24/24) (86 -
100%)d	100% (24/24) (86% -
100%)
	Overall	98% (47/48) (89% -
100%)	94% (44/48) (83% -
99%)	98% (47/48) (89% -
100%)	100% (48/48) (93% -
100%)

Table 1. Result of the Precision for the Cue COVID-19 Molecular Test.
-----------------------------------------------------------------------	--	--	--	--	--	--

4

Lot	Operator	Percent agreement with expected results (n/N) (95% Confidence Interval)
		Negative	C20-80	C95	C100
	Operator 1	100% (24/24) (86 -
100%)	79% (19/24) (58 -
93%)	100% (24/24) (86 -
100%)	100% (24/24) (86% -
100%)
	Operator 2	92% (22/24) (73 -
99%)	92% (22/24) (73 -
99%)	96% (23/24) (79 -
100%)	100% (24/24) (86% -
100%)
3	Overall	96% (46/48) (79% -
100%)	85% (41/48) (72% -
94%)	98% (47/48) (89% -
100%)	100% (48/48) (93% -
100%)
	Overall	97% (140/144)
(93% - 99%)	90% (129/144)
(83% - 94%)	97% (140/144)
(93% - 99%)	100% (144/144)
(97% - 100%)

"One cancelled test was repeated.

b One invalid result and one cancelled test were repeated.

One invalid result was repeated.

One cancelled test was repeated.

2. Linearity:

This study is not applicable as this test device is a qualitative assay.

3. Analytical Specificity/Interference:

a. Cross-reactivity
The cross-reactivity was evaluated by testing various bacteria (23), viruses (22), fungi (3), and pooled nasal wash with the Cue COVID-19 Molecular Test cartridge. Each organism or virus was tested by spiking of the microorganism onto a Cue sample wand. The crossreactivity was evaluated by the number of SARS-CoV-2 positive results against the expected negative results. The results, presented in Table 2, show that no cross reactivity was observed at the concentrations tested. except for SARS-CoV (coronavirus from 2003 SARS outbreak).

| Organism positive/
replicates tested |
|----------------------- | Bordetella pertussis | Chlamydia pneumoniae | Corynebacterium diphtheriae | Escherichia coli | Haemophilus influenzae | Lactobacillus plantarum | Legionella pneumophila | Moraxella/Branhamella catarrhalis | Mycobacterium tuberculosis | Mycoplasma pneumoniae | Neisseria meningitides | Organism positive/
replicates tested |
| Neisseria subflava | Pseudomonas aeruginosa | Staphylococcus aureus | Staphylococcus epidermidis | Streptococcus pneumonia | Streptococcus salivarius | Streptococcus pyogenes | Adenovirus Type 1 | Adenovirus Type 7 | Enterovirus Type 70 | Epstein Barr Virus | Human Coronavirus 229E | Human Coronavirus 0C43 | Human Coronavirus HKU1 | Human Coronavirus NL63 | MERS-Coronavirus (Inactivated) | Human Cytomegalovirus | Human Metapneumovirus | Measles | Mumps | Parainfluenza 1 | Parainfluenza 2 | Parainfluenza 3 | Parainfluenza 4 | Rhinovirus type 1 A | Respiratory Syncytial Virus B | Candida albicans | Influenza Type A | Influenza Type B | Mycoplasma genitalium | Aspergillus fumigatus | Organism positive/
replicates tested |
| Aspergillus flavus | Fusobacterium necrophorum | Bordetella parapertussis (E595) | Bordetella parapertussis (A747) | Pooled human nasal wash | P.jiroveci-S.cerevisiae | SARS Coronavirus (SARS-CoV) values from 25-28 | 1/3 | Concentration | SARS-CoV-2
--------------|--------------------------------------------------------|----------------------------------------------|
| $5.95 \times 10^7$ CFU/wand | 0/3 |
| $7.35 \times 10^5$ CFU/wand | 0/3 |
| $2.69 \times 10^7$ CFU/wand | 0/3 |
| $5.45 \times 10^6$ CFU/wand | 0/3c |
| $3.49 \times 10^6$ CFU/wand | 0/3 |
| $1.57 \times 10^7$ CFU/wand | 0/3 |
| $9.55 \times 10^7$ CFU/wand | 0/3c |
| $1.64 \times 10^5$ CFU/wand | 0/3 |
| $1.15 \times 10^6$ CFU/wand | 0/3c |
| $1.35 \times 10^6$ CFU/wand | 0/3 |
| $3.56 \times 10^6$ CCU/wand | 0/3 |
| Concentration | SARS-CoV-2
| 1.64 × 107 CFU/wand | 0/3 |
| 8.70 × 106 CFU/wand | 0/3 |
| 4.18 × 107 CFU/wand | 0/3 |
| 3.85 × 107 CFU/wand | 0/20b,c |
| 6.70 × 106 CFU/wand | 0/3 |
| 2.26 × 106 CFU/wand | 0/3 |
| 9.55 × 106 CFU/wand | 0/3 |
| 1.55 × 106 TCID50/wand | 0/20 |
| 2.29 × 104 TCID50/wand | 0/3 |
| 8.00 × 104 TCID50/wand | 0/3 |
| 3.93 × 105 copies/wand | 0/3 |
| 1.26 × 103 TCID50/wand | 0/3 |
| 5.25 × 103 TCID50/wand | 0/3c |
| 9.25 × 105 copies/wand | 0/3 |
| 5.50 × 103 TCID50/wand | 0/3a |
| 2.09 × 103 TCID50/wand | 0/3 |
| 2.09 × 103 TCID50/wand | 0/3 |
| 5.85 × 102 TCID50/wand | 0/3 |
| 8.00 × 102 TCID50/wand | 0/3 |
| 4.78 × 104 TCID50/wand | 0/3 |
| 6.30 × 103 TCID50/wand | 0/3 |
| 2.09 × 103 TCID50/wand | 0/3 |
| 4.26 × 105 TCID50/wand | 0/3 |
| 2.50 × 104 TCID50/wand | 0/3 |
| 7.55 × 103 TCID50/wand | 0/20 |
| 4.78 × 104 TCID50/wand | 0/3 |
| 2.51 × 106 CFU/wand | 0/3 |
| 4.80 × 104 TCID50/wand | 0/3 |
| 1.00 × 105 TCID50/wand | 0/3 |
| 7.19 × 106 copies/wand | 0/3 |
| 3.40 × 105 CFU/wand | 0/3 |
| Concentration | SARS-CoV-2
| $1.82 \times 10^5$ CFU/wand | 0/3 |
| $4.33 \times 10^6$ CFU/wand | 0/3 |
| $4.69 \times 10^7$ CFU/wand | 0/3 |
| $3.44 \times 10^7$ CFU/wand | 0/3 |
| (b)(4) | 0/3 |
Recombinant | (b)(4) CFU/wand | 0/3 |
| 10 fold dilution of stock with Ct
|

Table 2. Results of Cross-Reactivity Testing for the Cue COVID-19 Molecular Test.

5

6

10 One cancelled test was repeated.

b Two cancelled tests were repeated.

One invalid result was repeated.

CCU = color changing units

Additionally, cross-reactivity was assessed by in silico analysis of the test primers/probe sequences against the genome sequences of the microorganisms listed in the table above. Except for SARS-CoV (coronavirus from 2003 SARS outbreak), none of the test (0)|4) primer/probe sequences showed to any of the microorganisms analyzed.

b. Microbial Interference

Microbial interference was evaluated by testing various bacteria (22), viruses (21), and fungi (3) with the Cue COVID-19 Molecular Test cartridge. Each organism or virus was prepared, at the concentrations listed in Table 3, with inactivated SARS-CoV-2 (isolate USA-WA1/2020) at 3xLoD and then spiked onto Cue sample wands. The results, presented in Table 3, show that no interference was observed at the concentrations tested.

Table 3. Results of Microbial Interference Testing for the Cue COVID-19 Molecular Test.

| Organism | Concentration | SARS-CoV-2
positive/ replicates
tested |
|-----------------------------------|---------------------------|----------------------------------------------|
| Bordetella pertussis | (b)(4) × 107 CFU/wand | 3/3 |
| Chlamydia pneumoniae | 7.35 × 105 CFU/wand | 3/3 |
| Corynebacterium diphtheriae | 2.69 × 107 CFU/wand | 3/3 |
| Escherichia coli | 1.36 × 106 CFU/wand | 3/3 |
| Haemophilus influenzae | 3.49 × 106 CFU/wand | 3/3 |
| Lactobacillus plantarum | 1.57 × 107 CFU/wand | 3/3 |
| Legionella pneumophila | 9.55 × 107 CFU/wand | 3/3 |
| Organism | Concentration | SARS-CoV-2
positive/ replicates
tested |
| Moraxella/Branhamella catarrhalis | 1.64 × 105 CFU/wand | 3/3 |
| Mycobacterium tuberculosis | 1.15 × 106 CFU/wand | 3/3 |
| Mycoplasma pneumoniae | 1.35 × 106 CFU/wand | 3/3a |
| Neisseria meningitides | 3.56 × 106 CFU/wand | 3/3 |
| Neisseria subflava | 1.64 × 107 CFU/wand | 3/3 |
| Pseudomonas aeruginosa | 8.70 × 106 CFU/wand | 3/3 |
| Staphylococcus aureus | 4.18 × 107 CFU/wand | 3/3a |
| Staphylococcus epidermidis | 3.85 × 107 CFU/wand | 3/3 |
| Streptococcus pneumonia | 3.35 × 106 CFU/wand | 3/3 |
| Streptococcus salivarius | 2.26 × 106 CFU/wand | 3/3 |
| Streptococcus pyogenes | 9.55 × 106 CFU/wand | 3/3 |
| Adenovirus Type 1 | 1.55 × 106 TCID50/wand | 3/3 |
| Adenovirus Type 7 | 2.29 × 104 TCID50/wand | 3/3 |
| Enterovirus Type 70 | 8.00 × 104 TCID50/wand | 3/3b |
| Epstein Barr Virus | 3.93 × 105 copies/wand | 3/3 |
| Human Coronavirus 229E | 7.05 × 102 TCID50/wand | 3/3 |
| Human Coronavirus 0C43 | 5.25 × 103 TCID50/wand | 3/3 |
| Human Coronavirus HKU1 | 9.25 × 105 copies/wand | 4/4a,c |
| Human Coronavirus NL63 | 2.75 × 103 copies/wand | 3/3a |
| MERS Coronavirus | 2.09 × 103 TCID50/wand | 3/3 |
| Human Cytomegalovirus | 2.09 × 103 TCID50/wand | 3/3 |
| Human Metapneumovirus | 5.85 × 102 TCID50/wand | 3/3 |
| Measles | 8.00 × 102 TCID50/wand | 3/3 |
| Organism | Concentration | SARS-CoV-2
positive/ replicate
tested |
| Mumps | 4.78 × $10^4$ TCID50/wand | 3/3 |
| Parainfluenza 1 | 6.30 × $10^3$ TCID50/wand | 3/3 |
| Parainfluenza 2 | 2.09 × $10^3$ TCID50/wand | 3/3 |
| Parainfluenza 3 | 2.13 × $10^5$ TCID50/wand | 3/3 |
| Parainfluenza 4 | 2.50 × $10^4$ TCID50/wand | 3/3ª |
| Rhinovirus type 1A | 7.55 × $10^3$ TCID50/wand | 3/3 |
| Respiratory Syncytial Virus B | 4.78 × $10^4$ TCID50/wand | 3/3 |
| Candida albicans | 2.51 × $10^6$ CFU/wand | 3/3 |
| Influenza Type A | 4.80 × $10^4$ TCID50/wand | 3/3 |
| Influenza Type B | 6.50 × $10^3$ TCID50/wand | 3/3 |
| Mycoplasma genitalium | 7.19 × $10^6$ copies/wand | 3/3 |
| Aspergillus fumigatus | 3.40 × $10^5$ CFU/wand | 3/3 |
| Aspergillus flavus | 1.82 × $10^5$ CFU/wand | 3/3 |
| Fusobacterium necrophorum | 4.33 × $10^6$ CFU/wand | 3/3 |
| Bordetella parapertussis (E595) | 4.69 × $10^7$ CFU/wand | 3/3 |
| Bordetella parapertussis (A747) | 3.44 × $10^7$ CFU/wand | 3/3 |

7

8

a One cancelled test was repeated.

b One invalid result was repeated.

One additional test was run.

b. Interfering substances.

An interfering substances study was conducted to assess the performance of the Cue COVID-19 Molecular Test in the presence of medically and/or physiologically relevant concentrations of potentially interfering substances that may be present in anterior nasal swab specimens. Each potentially interfering substance was prepared, at the concentrations listed in Table 4, in negative clinical nasal matrix and in the presence of inactivated SARS-CoV-2 (isolate USA-WA1/2020) at 3xLoD. Samples were spiked onto Cue sample wands. The results, presented in Table 4, show that no interference was observed at the concentrations tested, except for false positive results in the presence of Saline Nasal Spray at 2.0 uL/wand, Chloroseptic lozenge at 2.0 uL/wand, and Rhinallergy 2.0 uL/wand. Limiting statements for these substances have been added to the labeling.

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| Substance | Concentration | SARS-CoV-2 positive/ replicates
tested | |
|---------------------------------|---------------|-------------------------------------------|----------------------|
| | | Negative Nasal
Matrix | 3xLoD SARS-
CoV-2 |
| Afrin | 2.0 µL/wand | 0/6 | 3/3 |
| Saline Nasal Spray | 2.0 µL/wand | 1/12 | 3/3 |
| Zicam Allergy Relief | 2.0 µL/wand | 0/3a | 3/3 |
| Chloroseptic Max | 2.0 µL/wand | 0/6 | 3/3 |
| Neo-Synephrine | 2.0 µL/wand | 0/6 | 3/3a |
| Nasacort | 0.4 ng/wand | 0/6a | 3/3 |
| Flonase/Fluticasone | 0.4 ng/wand | 0/6 | 3/3 |
| Flunisolide | 0.4 ng/wand | 0/6 | 3/3 |
| Dexamethasone | 5.0 ng/wand | 0/6 | 3/3 |
| Beclomethasone | 0.68 ng/wand | 0/6 | 3/3a |
| Mometasone | 0.4 ng/wand | 0/6a | 3/3 |
| Budesonide | 0.5 ng/wand | 0/6 | 3/3a |
| Chloroseptic Lozenge | 2mg/wand | 1/12 | 3/3 |
| Zanamivir (Relenza) | 3.0 ng/wand | 0/6 | 3/3 |
| Tamiflu (Oseltamivir phosphate) | 0.1ng/wand | 0/6 | 3/3 |
| Xofluza (baloxavir marboixil) | 0.1ng/wand | 0/6 | 3/3 |
| Mupirocin | 100 ng/wand | 0/6 | 3/3 |
| Tobramycin | 25ng/wand | 0/6 | 3/3 |
| Galphimia Glauca | 2mg/wand | 0/6 | 3/3 |
| Rhinallergy | 2mg/wand | 1/12 | 3/3 |
| Biotin | 0.035 ug/wand | 0/6 | 3/3 |
| Mucin | 0.5mg/wand | 0/3 | 3/3 |
| Whole Blood | 0.5µL/wand | 0/3 | 3/3 |

Table 4. Results of Interfering Substances Testing for the CoVID-19 Molecular Test.

a One cancelled test was repeated.

N/A = Positive Panel member was not tested at that substance's concentration.

4. Assay Reportable Range:

This section is not applicable as this test device is a qualitative assay.

5. Traceability, Stability, Expected Values (Controls, Calibrators, or Methods): a. Unopened Kit Stability

A multi-lot reagent stability study was conducted to establish the shelf-life of the Cue COVID-19 Molecular Test cartridge. Cartridges were stored at temperatures up to 25ºC. Three different lots were tested at monthly intervals for up to 9 months. Cartridge stability was evaluated by the agreement with the negative or positive results expected for the testing panel. The testing panel consisted of negative clinical nasal matrix spiked onto Cue sample wands or inactivated SARS-CoV-2 diluted into clinical nasal matrix and then spiked onto

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Cue sample wands at 3xLoD. Ten negative and 10 positive Cue sample wands were tested with each lot at each storage duration. All tested negative and positive Cue sample wands produced 100% agreement with the expected results. The study results demonstrated the stability Cue COVID-19 Molecular test cartridge for up to eight months when stored at 22℃.

b. Shipping Stability

A reagent stability study was conducted to establish the stability of the Cue COVID-19 Molecular Test cartridge under conditions representing the extreme temperatures and durations anticipated during shipping. Cartridges underwent the summer profile ( 1964) between 22°C and 40°C) for a total of | mirectly followed by the winter profile (10 (p)(4) between -10℃ and 18℃) for a total of . Finally, cartridges were held at controlled temperature and humidity for [ (0(4) | and then subjected to a series of vibrational and shock simulations. Cartridge stability was evaluated by the agreement with the negative or positive results expected for the testing panel. The testing panel consisted of negative clinical nasal matrix spiked onto Cue sample wands or inactivated SARS-CoV-2 diluted into clinical nasal matrix and then spiked onto Cue sample wands at 3xLoD. @ negative and [ ] positive Cue sample wands were tested with each lot at each storage duration. All tested negative and positive Cue sample wands produced 100% agreement with the expected results. The study results demonstrate the stability of the Cue COVID-19 Molecular test cartridge under anticipated shipping conditions.

6. Detection Limit:

a. Limit of Detection

An analytical sensitivity study was conducted to determine the limit of detection (LoD) for the Cue COVID-19 Molecular Test cartridge. The LoD is defined as the lowest concentration (copies per Cue sample wand, copies/wand) at which ≥ 95% of the replicates tested are positive. A preliminary LoD was established by testing four concentrations of inactivated SARS-CoV-2 (isolate USA-WA1/2020) diluted into clinical nasal matrix and spiked onto Cue sample wands. Forty-eight replicates were tested at each dilution by two operators over three days in two lots of the Cue COVID-19 Molecular Test cartridges. The preliminary LoD, established at 20 copies/wand, was confirmed by testing 20 additional replicates with each lot of Cue COVID-19 Molecular Test cartridges at 20 copies/wand and 10 copies/wand. The LoD for the Cue COVID-19 Molecular Test has been established at 20 copies/wand. The results of the LoD study are summarized in the Tables 5 and 6.

Copies/wand	Lot	% Detection (n/N)
	27251K	100% (24/24)
(b)(4)	27140B	100% (24/24)a
	27251K	100% (24/24)
60	27140B	91.7% (22/24)b
	27251K	95.8% (23/24)
20	27140B	95.8% (23/24)
	27251K	66.7% (16/24)
(b)(4)	27140B	62.5% (15/24)

Table 5. Results of the Preliminary LoD for the Cue COVID-19 Molecular Test.

" two cancelled replicates and one invalid replicate were retested.

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b one cancelled replicate was retested.

Copies/wand	Lot	Detection
	27251K	95% (19/20)
20	27140B	100%
(24/24)
	27251K	40% (8/20)
10	27140B	60% (12/20)

Table 6. Results of the Confirmatory LoD for the Cue COVID-19 Molecular Test.

8 one cancelled replicates and one invalid replicate were retested.

b one invalid replicate was retested.

c one cancelled replicate was retested.

b. WHO Testing Panel.

The analytical sensitivity was also evaluated using the First WHO International Standard for SARS-CoV-2 RNA. The analytical sensitivity for the Cue COVID-19 Molecular Test is established at 7.7×106 IU/mL using the First WHO International Standard for SARS-CoV-2 RNA.

7. Inclusivity

An analytical reactivity study was conducted to evaluate the ability of the Cue COVID-19 Molecular Test to detect multiple SARS-CoV-2 strains that are temporally and geographically diverse. Testing was performed on different strains of inactivated virus diluted into clinical nasal matrix and spiked onto Cue sample wands at 3xLoD. The results, presented in Table 7, show that strains were detected at 100% at the target concentrations.

Table 7. Results of Analytical Reactivity Testing for the Cue COVID-19 Molecular Test.

| Strain | Concentration
(copies/wand) | Percent Detected (n/3) |
|---------------------------|--------------------------------|------------------------|
| UK B.1.1.7 | 60 | 100% (3/3)a |
| Japan/Brazil P.1 | 60 | 100% (3/3) |
| Japan/Brazil P.1 | 60 | 100% (3/3) |
| South Africa B.1.351 | 60 | 100% (3/3) |
| US NY B1.526 | 60 | 100% (3/3) |
| US NY B1.526 | 60 | 100% (3/3) |
| India B.1.617.1 | 60 | 100% (3/3) |
| India B.1.617.2 | 60 | 100% (3/3) |
| India B.1.617.2 | 60 | 100% (3/3) |
| Italy-INMI1 | 60 | 100% (3/3) |
| Hong Kong/VM20001061/2020 | 60 | 100% (3/3) |
| USA-WA1/2020 | 60 | 100% (3/3) |
| Omicron lineage BA.1 | 60 | 100% (3/3)b |
| Omicron lineage BA.1.1 | 60 | 100% (3/3) |

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| Strain | Concentration
(copies/wand) | Percent Detected (n/3) |
|-----------------------|--------------------------------|------------------------|
| Omicron lineage BA.2† | 60 | 100% (3/3) |
| Omicron lineage BA.5† | 60 | 100% (3/3) |

"Two cancelled tests were repeated.

b One invalid result was repeated.

& genomic RNA was used for this strain instead of inactivated virus.

Additionally, inclusivity was assessed by in silico analysis of the test primers/probe sequences against the genome sequences of 353.513 SARS-CoV-2 variants circulating in the United States between March 2022 and November 2022 and deposited in the NCBI and GISAID databases. For strains showing mismatches to the test primers/probe, risk level was then assigned as follows:

· Risk level 1
- · A single mismatch was found in the forward and/or reverse primer alone.
- o A single mismatch was found at the 5' or 3' end of the probe.
- O Up to three deletions in the middle of the probe
· Risk level 2
- · A single mismatch in the middle of the probe.
- One to two mismatches found anywhere in the probe in addition to one to two mismatches in the forward and/or reverse primer.
- · Up to three deletions in the middle of the probe combined with a single mismatch in the middle of the probe.

Of strains found to be circulating between March 2022 and November 2022, 98.853% had no mismatches, 0.738% of strains were determined to be in risk level 1 and 0.415% of strains were determined to be in risk level 2. Mismatches were further investigated by creating 21 synthetic templates representative of the mismatches found across strains in risk levels 1 and 2. Synthetic templates were spiked onto swabs at various concentrations and tested using the Cue COVID-19 Molecular Test. Fourteen of these were detected at 60 copies/wand and seven were detected at between 200 and 600 copies/wand.

Cue Health continues to perform monthly surveillance of emerging SARS-CoV-2 strains by evaluating the test primers/probe, in silico, against sequences deposited in the NCBI and GISAID databases. Updated information on detection of emerging variants of concern can be found at www.cuehealth.com.

1. Assay Cut-Off:
  The assay cutoff was determined in a limit of blank (LoB) study conducted in accordance with CLSI EP17-A2 as the 97th percentile of blank samples results.

9. Accuracy (Instrument):

Please refer to Section VI.C (Clinical Studies) for the clinical evaluation study and data that establish clinical performance and accuracy of the test device.

10. Carry-Over:

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A study was conducted to demonstrate that there is no carryover between samples when using the Cue Reader. In this study, negative clinical matrix samples were processed on the same reader following a high positive sample. In total sixteen samples of alternating negative and positive were run on five Cue Readers each for a total of 40 positive observations and 40 negative observations. All test results were as expected. No evidence of carryover was observed.

B Comparison Studies:

1. Method Comparison:

Please refer to Section VI.C (Clinical Studies) below for the clinical validation, regarding the method comparison studies.

1. Matrix Comparison: Not Applicable.

C Clinical Studies:

A prospective all-comer study enrolled subjects at 13 sites, from December 2020 - February 2021 and November 2021- February 2022 to evaluate the clinical performance of the Cue COVID-19 Molecular Test in symptomatic individuals. Cue system set-up, sample collection, and testing were completed by each subject in a simulated home environment. Each subject was allowed " minutes to obtain a Cue COVID-19 Molecular Test result, including a retest if needed due to an initial canceled test or invalid result. A nasal swab sample was then collected by a trained operator for comparator testing. A consensus comparator (agreement between at least two FDA Emergency Use Authorized (EUA) molecular tests for SARS-CoV-2) was used for method comparison.

(DICS) One subject was excluded due to a protocol deviation; subjects were excluded due to no available Cue result; Subjects were excluded due to no available comparator result. There were 902 evaluable subjects with (b)(4) 1902) male (0)(4) 1902) female, 000 nonbinary, and with unreported gender. The age of participants ranged from 18 years old to 87 years old, with a mean of 40.9 years. The education level of subjects ranged from high school to post-graduate. Results obtained with the Cue COVID-19 Molecular Test were compared to the results obtained with the consensus comparator to determine clinical performance. The results are presented in Table 8.

| | EUA authorized RT-PCR
Consensus Comparator | | Total |
|---------|-----------------------------------------------|-----|-------|
| | Pos | Neg | |
| Cue Pos | 130 | 10 | 140 |
| Cue Neg | 10 | 752 | 762 |
| Total | 140 | 762 | 902 |

Table 8. Clinical performance of the Cue COVID-19 Molecular Test.

Positive Percent Agreement (PPA) = 92.9% (130/140) (95% CI: 87.4% = 96.1%) .

Negative Percent Agreement (NPA) = 98.7% (752/762) (95% CI: 97.6% 99.3 %) .

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1. Clinical Sensitivity:
  Please refer to Section VI.C (Clinical Studies) above for the clinical validation. The PPA for the test is 92.9% (130/140) (95% CI: 87.4% - 96.1%)
1. Clinical Specificity:
  Please refer to Section VI.C (Clinical Studies) above for the clinical validation. The NPA for the test is 98.7% (752/762) (95% CI: 97.6% - 99.3%)

D Clinical Cut-Off:

There is no clinical cutoff related to the presence of SARS-CoV-2 in patient samples. This section is therefore not applicable.

E Expected Values/Reference Range:

In the Cue COVID-19 Molecular Test clinical study (described in the "Clinical Studies" section above), 246 anterior nasal swab specimens, collected during December 2020 - February 2021 and 656 anterior nasal swab specimens, collected during November 2021- February 2022, were determined to be evaluable. The number and percentage of SARS-CoV-2 positive cases per collection period, as determined by the Cue COVID-19 Molecular Test, are:

(0)(4) . Positivity from December 2020 - February 2021 = (246)
Positivity from December 2020 February 2021 = . V656) (0)(4)

F Other Supportive Performance Characteristics Data:

1. Usability and User Comprehension

A usability was conducted to assess lay users' execution of Cue Reader set up and Cue COVID-19 Molecular Test workflow. A total of 95 subjects, ages 18 years and older, were enrolled in the study. 98% (93/95) successfully completed testing by receiving a Negative or Positive result for the initial test or upon retest. One subject did not receive a valid Cue test result because no more test cartridges remained for a retest. One subject received a canceled test upon both initial testing and retesting.

Following the usability portion of the study, all subjects were issued a questionnaire. User comprehension was also assessed via a questionnaire completed by 776 subjects enrolled in the clinical study. The questionnaire assessed users' understanding of label comprehension concepts such as the test purpose, interpretation of results, and follow-up actions. The outcome of the study was used to validate the mitigations in the labeling.

2. Frequently Asked Questions

To improve user label comprehension, the labeling includes a Frequently Asked Questions (FAQ) section. The FAQ section was created to provide users information to adequately understand the purpose, limitations, and meaning of the test results as well as where users can access additional information regarding SAR-CoV-2 pathology and epidemiology. The concepts covered in the FAO section include:

The purpose of the test and description of the test and the analyte. .

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Who should and who should not use the test (self-selection). .
Meaning of the test results. .
. When to re-test (e.g., following an invalid result).
Follow-up for appropriate health management. .

3. Hazard Analysis

A comprehensive hazard analysis of the Cue COVID-19 Molecular Test was conducted in accordance with ISO 14971:2019. The hazard analysis included identification of the potential hazard, likelihood of occurrence, severity of potential harm, hazard control measure(s), hazard control verification, and assignment of pre- and post-control risk levels. The elements considered included operator errors (i.e., human factors), sample and device handling and storage, and environmental factors.

Potential sources of errors that could adversely affect system performance were identified and mitigated first through system design and then through additional cautions in the labeling. The identified risks which could result in erroneous test results were evaluated in flex studies that evaluated the functionality of fail-safe mechanisms and stressed the functional limits of the test system (see below)

4. Failsafe Features

The device features a number of failsafe features designed to minimize false results due to user error:

. Internal Control - Monitors for presence of human specimen material; monitors for the execution of each step in the test chemical reaction.
Internal system timer Monitors for system timing with respect to cartridge and wand . insertion; monitors for correct wand insertion.
. Tilt sensor - Monitors for correct test system positioning.
Temperature Sensor Monitors test system temperature; prevents use of cartridges which . are not equilibrated to room temperature.
. Cartridge Expiration date sensor - Prevents use of expired cartridges.
Used Cartridge sensor Prevents use of used cartridges. .
Battery Charge Sensor Prevents use of test system when the Cue Reader battery is