Objective Primary chronic rhinosinusitis (CRS) is typically a diffuse process and the extent of endoscopic sinus surgery (ESS) performed for medically recalcitrant CRS is impacted by many factors. However, some third‐party payors have implemented policies to authorize coverage for ESS in a sinus‐by‐sinus manner based on a minimal measurement of millimeters of mucosal thickening or sinus opacification in the corresponding sinus that is being surgically addressed. Our objective was to determine whether such policies are based on scientific evidence that in patients with medically recalcitrant CRS, a minimum measurement of mucosal thickening or sinus opacification is a predictor of CRS in that sinus or improved outcomes after ESS on a sinus‐by‐sinus basis. Data Sources Medline, Embase, Scopus, and Web of Science databases, from inception through May 2022. Review Methods A systematic review was performed. The Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines were followed. Results We identified 6070 s which were screened and from which 112 studies ultimately underwent a full‐text review. From these studies, we found that none investigated (or provided evidence of) whether any minimal degree of radiographic mucosal thickening or sinus opacification predicted CRS or better outcomes after ESS in a sinus‐specific manner. Conclusion We were unable to find evidence supporting a minimum millimeter measurement of mucosal thickening or sinus opacification as predictors of CRS or better post‐ESS outcomes in a sinus‐specific manner in patients with medically recalcitrant CRS. The extent of ESS for CRS should be determined through personalized medical decision‐making that considers all patient‐specific factors.