Can anyone think of programs where an applicant's chances are significantly reduced if they aren't AOA, regardless of how admirable the rest of their application may be? I'm well aware that AOA is generally just icing on the cake at most programs and is in no way a requirement, but I'm curious if anyone (esp. residents) knows of any truly competitive programs where it actually might make a big difference.

more specifics:
consider an applicant with tons of honors (not all though). a step 1 in the upper 240's, plenty of research, awards, extra curricular stuff, great LORs, a good personality, and whatever else. Obviously, this person has a pretty good chance of being ranked well at most places, but are there places where he/she may be significantly lower on a rank list simply based on not making AOA?