It is still the most demanding setting and Medium has more foliage but looks naff.
Nope. If you get the medium (i.e. full ultra) to activate it is more demanding and everything looks way better. I was shocked as to how much better Golmud Railway looked with all the proper terrain decoration on...
It is a faff though because you have to remember to change it back to ultra before quitting then change it back to medium when you restart the game.